Sorry, don't think the miconazole is a good test.  Why should 24 hours
of treatment do the trick?  Even wonderful gentian violet takes a few
days.  She didn't try that, though, and that is a good test.  Worth a
go.

        When nothing else works, particularly in unusual situations, I often
use my "good-for-all-things-don't-know-why-it-works" nipple ointment.
Unfortunately, it requires a prescription, and I think, is not available
in the US.  This is even though it is an American company (aren't they
all?) which makes Kenacomb.

        Kenacomb contains two antibiotics (not absorbed from the gi tract),
nystatin, and triamcinolone (a relatively strong steroid).  I suggest to
the mother she apply it after each feeding and not to wash it off or
wipe it off when putting the baby back to the breast.  The company that
makes Kenacomb is Westwood-Squibb.  Maybe if you want to try it, the
company has the same product under a different name in the US.  The
exact ingredients are (so a pharmacist can make it up from
scratch--something they used to do, you know):

each gram contains:
triamcinolone acetonide 1 mg,
neomycin base (as sulfate) 2.5 mg
gramicidin 250 micrograms
nystatin 100,000 units

The ointment is formulated in protective Plastibase (Squibb plasticized
hydrocarbon gel).  It probably does not need both antibiotics, and
either the neomycin or gramicidin could be left out, though it is
probably better to leave out the neomycin as it is more likely to cause
contact dermatitis.  Other companies probably have similar preparations.
If find the ointment works better.

Jack Newman, MD, FRCPC

PS I know all pharmaceutical companies are not American.  Some are
Swiss.