Am chiming in a bit late (sorry) on the recent breast-pain thread.  Have
been working with breastfeeding moms for over 20 years and have seen the
pendulum swing from denial that any mother might have nipple/breast
candidiasis to tendency to prescribe fluconazole for any mom who calls in
with deep breast pain after feeding.  I hear from the moms who have had
weeks of fluconazole with no change in symptoms and following have been the
actual causes of the pain:

Latch problems, including ankyloglossia, becoming symptomatic as late as 4-6
months. (the nipples just can't take it any more??)

Fissures and bacterial infections.

Dermatitis in response to various and sundry "nipple butters".

Eczema

Pendulous breasts with no support from ancient bra, active infant
practically swinging on nipple.

Ductal bacterial infection - no acute symptoms, just persistent, miserable
deep breast pain.

Occasionally I find what I suspect to be true superficial candidiasis.
These cases resolve promptly with 2% miconazole nitrate used diligently.
Perhaps some mupirocin if hint of secondary bacterial infection. It has been
my experience that if miconazole (properly used) fails then I was wrong
(eek) about the candidiasis - mom needs to see  dermatologist asap.  Skin is
skin, no matter where it is;  the only problem a dermatologist might have is
excessive caution re which meds can be used in a breastfeeding mom. This can
(my experience) be resolved by connecting Ped and Derm.

Oddly I have not found that fluconazole helps nipple candidiasis - but
remember I am only seeing those women who have failed a sufficient course of
fluconazole.  None of the happy ones helped by fluconazole call/see me!
Jack Newman talks about increasing resistance to fluconazole so perhaps I'm
seeing this?

Joanna Koch, IBCLC

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