Abstract
Case study
A 32-year-old mother presents with severe breast pain on breastfeeding her infant and a 6-month history of redness and dryness around the nipple of the left breast. She has been using multiple antibiotics and emollients as prescribed by her previous GP without relief. She has a history of several past episodes of vaginal candidiasis with white discharge and itching. On examination the skin is red on the inferolateral side of areola, tender, dry and scaly. On examination the baby has no signs of candidal infection and there is no current vaginal infection.
Swabs are taken and treatment started with oral nystatin for the infant and topical nystatin applied to the affected breast for 14 days. However, symptoms recur after stopping treatment. Treatment for the recurrent infection with 7 days of oral fluconazole is successful.
Dr P. Marazzi/Science Photo Library
This is candida mastitis
Candida albicans, a commensal organism encountered frequently in the vagina and gastrointestinal tract of humans, is responsible for both cutaneous and ductal infections of the breast in lactating women. When diagnosing mastitis vigilance is required as repeated infections can lead to ductal candidiasis. It is severe pain that causes mothers to consult. The pain is typically stabbing in character and associated with breast feeding. There may also be a history of burning pain affecting nipples or areola and soreness of the nipples.
Risk factors include recurrent vaginal candidiasis, antibiotic use and intake of large amounts of dairy or sweet foods by lactating mothers. Treatment is with small amounts of miconazole 2% cream applied to the affected nipple after every feed. Miconazole is preferred as there are high rates of resistance to Nystatin. If the nipples are very red and inflamed, a combination of miconazole 2% with hydrocortisone 1% cream can be applied. Treatment often includes the addition of a topical antibiotic to combat staphylococcus aureus infections associated with nipple fissures. Oral fluconazole may be considered for persistent infections and where there is spread of infection into the ductal system. Treatment for the baby is with nystatin oral suspension 100 000 units (1 ml) four times daily after feeds, or Miconazole gel 1.25 ml gently smeared around the baby’s mouth four times a day after feeds. Early recognition and treatment aims to support successful long-term breastfeeding.
ORCID iD
Maryam Paracha https://orcid.org/0000-0002-4045-1274