My lady with extreme engorement that I was seeing last week, now
has the worst case thrush I have ever seen......  She is in agony
and has weaned the baby because she couldn't even express by
hand or pump.  Anyway, she has been taking an antifungal since
Friday and is still in pain, deep breast pain.  She is applying
Daktarin gel to her nipples, treating the baby....She says that the cream
is
burning her nipples and that the antifungals orally are not relieving
the symtoms at all so far

Hi Val, yes Daktarin oral gel can burn the nipples (as can anything
actually). I would try nystatin ointment as there seems to be less reaction
to this. If fluconazole is too expensive, she may consider ketoconazole
(Nizoral) which is well absorbed. There have been reports of liver damage
(1 in 10,000 patients) so we don't usually use in lactating women, but if
she's decided to wean she may want to try it. Otherwise, continue on the
nystatin, at least 2 caps 3 times a day. Has she cut out sugar? Another
thing to consider is that the engorgement is probably exacerbating the
thrush pain.
Lisa Amir
GP / IBCLC in Melbourne, Australia - back to euthyroid (ie normal thyroid
function), yea!