Breast candidiasis, nipple candidiasis or thrush and breastfeeding: an update in 2025

Elise Armoiry My Baby Moon
Dec 2, 2025
6 min read

Several recent publications report a possible overdiagnosis of breast candidiasis (also called breast yeast infections). In a context of medication shortages, healthcare professionals are finding it increasingly difficult to know which product to prescribe when a candidiasis is suspected.

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Breast candidiasis is very likely overdiagnosed, as indicated in the Academy of Breastfeeding Medicine Clinical Protocol #26 and by various authors (1,2,7–9, 12, 14).

This article reviews candidiasis and other possible causes of nipple pain and pain radiating into the breast.

If you experience pain during feedings: nipple pain, breast pain, cracks, pain after feeding: you can contact me.

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Nipple candidiasis is caused by the fungus Candida albicans. This fungus is a normal inhabitant of the skin flora. Under certain conditions, it can proliferate and cause painful symptoms, for example in cases of vaginal yeast infection or athlete’s foot.

Factors that promote nipple candidiasis

Maceration in a warm and humid environment: breast pads changed too infrequently, use of seashell breastfeeding shells
a crack that has macerated in a moist environment with a seashell
Antibiotic therapy in the mother or baby, diabetes, corticosteroid therapy, oral contraception

History of the hypothesis of breast candidiasis in breastfeeding women

Since the 1990s, the hypothesis of breast candidiasis as a cause of persistent nipple pain or radiating breast pain has spread in the breastfeeding field. It originated partly from several comparative studies between two groups of breastfeeding women: one group with pain and one without pain, showing more presence of Candida in breast milk and on nipples in the painful group. Sometimes, thrush was also found in the baby, leading to the conclusion that Candida was transmitted between mother and baby.

Historically, symptoms of breast candidiasis included signs generally appearing after several weeks of painless breastfeeding, after a pain-free period, and affecting both breasts.

The described signs were:

Signs of suspected candidiasis in the mother:A bright pink or sometimes discolored areola, shiny appearance, sometimes with scaling, nipples that may show cracks; painful latch, itching, nipple burning, pain radiating into the breast a few minutes after feeding, after every feeding, sometimes even without changes in the appearance of the areola.
Signs in the baby in cases of breast candidiasis:The baby may have no thrush in the mouth but significant diaper rash, or actual thrush (white coating on the tongue and inside the cheeks that does not rub off with a damp compress), as well as fussiness during and after feeding due to pain.

Historically recommended measures in case of candidiasis diagnosis

Historically, a diagnosis of breast yeast infection led to a series of measures.

Improving positioning was advised in order to reduce latch pain, along with hygiene precautions: washing bras (and cloths, towels—anything in contact with breasts or the baby’s mouth) at high temperature (at least 50°C), sterilizing pacifiers, nipple shields, and pump parts.
Various treatments were recommended to relieve pain:
- Sodium bicarbonate or vinegar applied to the nipple to modify pH and limit Candida proliferation, along with other suggested topical applications such as grapefruit seed extract or coconut oil.
- Long antifungal drug treatments of 21 days: it was recommended to treat both mother and baby to prevent reinfection.
- For nipples: medications could be used topically, such as miconazole (Daktarin). As a second-line oral agent: fluconazole.
- For the baby’s mouth: nystatin or amphotericin B (Fungizone), depending on the child’s age.

Recently, supply shortages and stock outages have affected these treatments, making management more difficult.

It has been well established for several years that:

Gentian violet should be avoided due to risk of adverse effects (oral ulcerations—see ANSM alert).

The Newman ointment (all-purpose nipple ointment containing mupirocin, betamethasone, miconazole, and ibuprofen) has not demonstrated effectiveness for nipple pain in a 2014 Cochrane review, and due to its composition, it carries risks of microbial resistance and allergies. Its use is discouraged by several authors (P. Douglas and K. Mitchell in particular).

Breast candidiasis called into question

Several publications since 2016 challenge this hypothesis of breast candidiasis:

We learn that Candida is a normal inhabitant of skin flora: 37% of infants are colonized with Candida at day 7, 82% at 1 month.

Several studies on breast milk and its mycobiome show that Candida is a usual component of milk flora, including in asymptomatic mothers in neonatal units, with variations depending on mode of birth and gestational age.

There are studies reporting cases of radiating breast pain without higher levels of Candida in the pain group. For example, in 2016 Mutschlechner et al. reported breast milk PCR analysis: among 40 symptomatic women, 8.8% had Candida; among 40 asymptomatic women, 9.3% had Candida. Some authors have suggested a bacterial hypothesis for these pains, without strong evidence (Jimenez, Amir).
Analysis methods that previously suggested more Candida in pain cases have been called into question (especially RT-PCR), with the possibility of false positives.
Symptoms such as redness, shiny skin, or nipple burning may correspond to contact dermatitis or eczema, particularly if maceration occurred (breast shells, silver cups) or due to products that may cause allergies (such as lanolin).
Mother–baby transmissibility is also being questioned (see K. Mitchell’s blog), as well as the need for hygiene precautions traditionally recommended.
Ultimately, recent studies challenge diagnoses of breast candidiasis, especially in cases of persistent radiating breast pain or nipple burning without changes in appearance.

What are the other possible causes of nipple and breast pain?

I invite you to consult the documents in the bibliography for more detail, but these include:

A latch/position problem causing repeated micro-trauma, leading to inflammation and radiating breast pain. The perceived effectiveness of antifungals is likely due to local anti-inflammatory effects.
Low milk supply: the baby feeds very frequently and pulls on the breast, causing pain.
Nipple vasospasm.
Nipple dermatitis (including eczema; note that lanolin is a very common allergen!): see Katrina Mitchell's blog, A Physician Guide to Breastfeeding, which presents numerous clinical case photos.
Oversupply: the baby clamps the nipple to manage milk flow, which also promotes milk blisters/blocked ducts/engorgement/mastitis.
Incorrect pump use.
Bacterial or viral infection.
Overhydration of the nipple which, according to Dr. Douglas, causes skin lesions and is promoted by various ointments and maintenance of humidity (hydrogel pads, breast milk compresses, pads, breast shells, etc.).

And if it really is a nipple yeast infection?

In cases of persistent pain despite positional adjustments and when contributing factors are present (e.g., antibiotic therapy), Dr. Pam Douglas suggests airing the nipples and using a short course of fluconazole.

Dr. Katrina Mitchell questions routine treatment of the mother when thrush is found in the baby, as well as hygiene measures such as sterilizing pump equipment.

Conclusion

In conclusion, in cases of radiating breast pain, before starting antifungal treatments, especially in a context of microbial resistance and medication shortages, it is important to first review breastfeeding techniques, particularly latch and positioning.

Disclaimer: This article is intended to provide general information and does not replace medical advice. It is essential to consult a healthcare professional for any questions related to your personal situation.

Bibliographic references

Identifying the cause of breast and nipple pain during lactation Lisa H Amir et al . BMJ 2021;374:n1628 http://dx.doi.org/10.1136/bmj.n1628
Plachouri KM, Mulita F, Oikonomou C, Papadopoulou M, Akrida I, Vryzaki E, Verras GI, Georgiou S. Nipple candidiasis and painful lactation: an updated overview. Postepy Dermatol Alergol. 2022 Aug;39(4):651-655. doi: 10.5114/ada.2022.116837. Epub 2022 May 31. PMID: 36090722; PMCID: PMC9454364.
Ouvrage de Nancy Mohrbacher : Breastfeeding answers, 2020
ANSM: violet de gentiane, 2022
site de la leche league GB
Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev. 2014 Dec 15;2014(12):CD007366. doi: 10.1002/14651858.CD007366.pub2. PMID: 25506813; PMCID: PMC10885851.
Douglas P. Re-thinking lactation-related nipple pain and damage. Womens Health (Lond). 2022 Jan-Dec;18:17455057221087865. doi: 10.1177/17455057221087865. PMID: 35343816; PMCID: PMC8966064.
Douglas P. Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women. Womens Health (Lond). 2021 Jan-Dec;17:17455065211031480. doi: 10.1177/17455065211031480. PMID: 34269140; PMCID: PMC8287641.
ABM Clinical Protocol #26: Persistent Pain with Breastfeeding
Johnson H, Norman T, Adler BL, Yu J. Lanolin: The 2023 American Contact Dermatitis Society Allergen of the Year. Cutis. 2023 Aug;112(2):78-81. doi: 10.12788/cutis.0825. PMID: 37820332.
NHS. Breastfeeding and thrush
Betts RC, Johnson HM, Eglash A, Mitchell KB. It's Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain. Breastfeed Med. 2021 Apr;16(4):318-324. doi: 10.1089/bfm.2020.0160. Epub 2020 Dec 10. PMID: 33305975.
Lactmed-Nystatin
Jiménez, Esther et al. “Mammary candidiasis: A medical condition without scientific evidence?.” PloS one vol. 12,7 e0181071 (2017). doi:10.1371/journal.pone.0181071
blog de Katrina Mitchell. A physician guide to breastfeeding. Yeast