The different etiologies for sore nipples are: 1. infection (bacterial and/or candidal) 2. mechanical 3. Nipple vasospasm 4. Paget's disease .
1. One cannot rule out candida with testing the breastMILK as there is a high rate of false negatives. This rate can be decreased by adding ferrous sulfate to the milk and culturing them on a SDA plates. I doubt the dermatologist did this. It is however, fairly accurate to culture the nipple/areolar area separately. If the lab uses a germ tube to determine the presence of candida it can miss C. dublinesis.
2. If it is mechanical then I have found that moms just need to use the nipple shield most of the time and at about 4 months it starts to work.
3. For nipple vasospasm--asking the mother to note any nipple color changes is the first step. Applying ice to the nipple is a test you can use.
4. Paget's disease presents as a nipple with eczematous changes. The nipple can be reddened, sore or itchy/burning. IT can wax and wane. Sometimes the nipple inverts. These symptoms can be subtle or extremely obvious.
Lastly, she can have a combination of the above etiologies.
My gut feeling is that she needs treatment with bactroban and OTC yeast med or that she has some oroboobular discombobulation leading to recurrent trauma.
Christine Betzold NP CLC MSN
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