Too bad about gentian violet in the old British Empire.  We in Canada
were probably saved because we are not only part of the British
Empire, but also the American Empire.

If a mother had a definite yeast infection of the nipples, I would
treat the baby intensively with nystatin, asking the mother to rub the
stuff into the baby's cheeks and all around his mouth *after each
feeding*.  I would also treat the mother with a ointment called
Kenacomb, which contains nystatin and a steroid (because the
inflammation is causing the pain).  It also contains two non
absorbable antibiotics which are helpful if the mother has cracks or
erosions.  I ask the mother to use the Kenacomb ointment after each
feeding and not to wash or wipe if off before putting the baby back to
the breast. If you do not have this preparation in the old British
Empire, I'm sure there is something else which is almost the same.
You might speak to a pharmacist.  Here is the makeup:

Each gram of ointment contains:
triamcinolone acetonide 1 mg
neomycin base (as sulphate) 2.5 mg
gramicidin 250 micrograms
nystatin 100,000 units.
The ointment is formulated in a polyethylene and mineral oil gel base.

Undoubtedly, one of the antibiotics can be chucked out.  I find the
ointment far better than the cream.

If oral treatment is necessary, ketoconazole can be used.  The dose in
the mother is 200 once or twice daily for about 10 days to 2 weeks.
Its disadvantage is that it is not excreted into the milk as well as
fluconazole (here this is a disadvantage).  But it is a lot cheaper
(maybe 1/5th the price of fluconazole).  For this reason I usually
treat the baby as well.  The dose for a baby is 5 to 10 mg/kg/day for
the same time period.  The mother does not have to stop breastfeeding,
just as she does not have to stop breastfeeding because she is taking
fluconazole.

I find that creams containing clotrimazole do not work well (from my
patients, but if they worked well, they would not have come to see me,
since I never prescribe it).  I think they often cause contact
dermatitis as well.

Jack Newman, MD, FRCPC