I read the following in a medical journal yesterday:

"neuropathic pain originates in teh nervous system itself, unlike the
'classical' pain triggered by external injury. The term neuropathic pain
generally includes any acute or chronic pain syndrome characterized by a
continous pain, usually burning in quality, associated with throbbing,
aching and tingling component."

I know this has been postulated in the past for some of the mothers I have
seen with Candidal pain. I have usually not given it the thought I perhaps
should have. We have some mothers who seem to have candida, but do not
respond to even large doses of fluconazole for long periods of time. I never
believed this was due to "low grade" infection with staph (pace Tom Hale),
but obviously something else was going on. Perhaps it is neuropathic pain.

Treatment is to find out the cause (frequently diabetes, but in our patients
could be secondary to earlier trauma), but this is often not fruitful. The
author suggests treatment as follows:

amitryptiline, nortriptyline or desipramine, starting with 10 to 25 mg at
bedtime, then "titrate by adding one tablet (10 or 25 mg) every 5 to 7 days.
Most patients will report significant pain relief within the dosage range of
30-100 mg/day." Side effects, however, are common and he recommends other
drugs if tricyclics don't work:

carbamazepine, phenytoin or gabapentin. The first two are safe during
lactation and the third probably is, but there is little information
available on its use in lactation. The usual dose of carbamazepine is
400-1200 mg/day in divided doses, with an initial dose of 100 mg twice a
day. phenytoin is usually prescribed at a dose of 300 mg/day.

For those who have desperate mothers whose physicians will not prescribe
fluconazole, perhaps trying this tack might help the mothers.

If anyone has more information about neuropathic pain please let me and the
list know. This could be an interesting study, actually, to treat mothers
with breast pain with placebo, fluconazole and say amytriptiline (3 groups).

I will try contacting the author of the article to see what he thinks of the
"typical" pain of candida. I am not saying there is no more candida pain, by
the way. Just that when mothers don't respond, perhaps we have another
possibility of treatment that does not include weaning.

Jack Newman, MD, FRCPC

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