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Fluconazole
Handout #20 Fluconazole revised January
2005
Written by Jack Newman, MD, FRCPC. © 2005
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Fluconazole (Diflucan™) is a synthetic antifungal
agent that can be used for the treatment of a variety of Candida
albicans and other fungal infections. For the breastfeeding
mother in particular, it can be used to treat recurrent Candida
infections of the nipples, and, if such a thing exists, as I believe
it does, Candida infections of the milk ducts.
Candida (yeast) infections of the nipple
and ducts
Candida infections of the nipples may occur
any time while the mother is breastfeeding. Candida albicans
likes warm, moist, dark areas. It normally lives on our skin and
other areas, and 90% of babies are colonized by it within a few
hours of birth. It, like many other germs that live on us normally,
only becomes a problem under certain circumstances.
Candida infections of the skin or mucous
membranes are more likely to occur when there is a breakdown in
the integrity of the skin or mucous membrane—another reason
why a good latch is very important from the very first day. Many
Candida infections would, perhaps, not have occurred
if the mother had not had sore nipples and a breakdown of the
skin of the nipples and areola. The oozing of liquid that occurs
often in cracked nipples encourages Candida albicans
to change from its harmless form to a disease causing form.
The widespread use of antibiotics also encourages
the overgrowth of Candida albicans. Many pregnant women,
women in labour, and new mothers, as well as their babies receive
antibiotics, sometimes with very little justification.
Diagnosis of Candida infections of the nipples
and/or ducts
There is no good test which helps makes the diagnosis.
A positive culture from the nipple(s) does not prove your pain
is due to Candida. Neither does a negative culture mean
your pain is not due to Candida. The best way to make
a diagnosis is by history.
The presence or absence of a Candida infection
in the baby is not helpful. A baby may have thrush all over his
mouth, but the mother may have no pain. A mother may have the
classic symptoms of a Candida infection of the nipples,
and the baby may have no thrush or diaper rash.
The typical symptoms of a Candida infection
of the nipples are:
-
Nipple pain that begins after a period
of pain free nursing. Though there are a few other causes of
nipple pain that begin later, Candida infection is
definitely the most common. The nipple pain of Candida
may begin without an interval of pain free nursing, however.
- Burning nipple pain that continues throughout
the feeding, sometimes continuing after the feeding is over.
- Pain in the breast that is “shooting” or “burning”
in nature and which goes through to the mother’s back and
shoulder. This pain is usually worse toward the end of the feeding,
and worsens still more after the feeding is over. It
also tends to be much worse at night. This pain may occur without
any nipple pain.
- Pain, as above, which is made much better with the use of gentian
violet, though unfortunately, gentian violet does not seem to
work as well as it used to.
Treating Candida Infections
Our first approach to treating these infections is
gentian violet (handout #6 Using
Gentian Violet) plus all purpose nipple
ointment and sometimes grapefruit seed extract (see handout #3b
Treatments for Sore Nipples and Sore Breasts and Handout
C: Candida
Protocol). This approach is safe, works rapidly, and almost
always, though there seems to have been a decrease in the effectiveness
of gentian violet over the past few years. For this reason, I now
use the combination of the ointment and the gentian violet as well
as the grapefruit seed extract. A good response to gentian violet
confirms that the mother’s nipple pain is caused by Candida
since little else will respond to gentian violet. It thus also justifies
the use of fluconazole, if needed. Even if the above treatment does
not help, fluconazole should not be used alone to treat sore nipples
and should be added to treatment on the nipples, not used
instead. I have not found nystatin to be particularly useful either
in treatment of the baby’s mouth or in the treatment of the
mother’s nipples. Clotrimazole cream alone is also not particularly
effective in my opinion, but others obviously feel differently.
Fluconazole
Fluconazole is an antifungal agent that is taken systemically
(by mouth or intravenously). It stops fungi (such as Candida
albicans) from multiplying, but does not actually kill them.
This accounts for the fact that sometimes it takes several days
to have an effect. Fluconazole powder is also available and can
be mixed with the all purpose nipple ointment instead of miconazole
powder.
Side Effects
Fluconazole is generally well tolerated, but there
is no such thing as a drug that never has side effects.
Concern about liver injury is exaggerated, since this complication
seems quite rare, and usually occurs in people who are taking other
medications as well, and who have taken fluconazole for months or
longer, and who have immune deficiencies. But it is a possibility
that needs to be kept in mind and if it does occur, it can be very
serious.
Vomiting, diarrhea, abdominal pain and skin rashes
are the most common side effects. These are not usually severe,
and only occasionally is it necessary to stop the medication because
of these side effects. Allergic reactions are possible but uncommon.
Call or email immediately if you have any concerns.
Fluconazole in the milk
Fluconazole does appear in the milk, and this is as
it should be, since the idea is to treat infection in the ducts
and nipples. It is thus superior to ketoconazole, which gets into
the milk in only tiny amounts. The baby will obviously get some,
but this drug is now being promoted for use in babies for the treatment
of simple thrush. There have been no complications in the
baby reported from exposure to fluconazole in the breastmilk. Continue
breastfeeding while taking fluconazole, even if you are
told that you should stop.
Dose of fluconazole
Candida albicans is learning to become resistant
to fluconazole, and the dose we use has increased over the past
few years. Only a few years ago, 100 mg daily for 10 days cured
90% of women of their symptoms. We have now found this to be inadequate.
For resistant cases, a newer antifungal agent, itraconazole, can
be used, though it may not be the answer either as it does not have
a very powerful effect against Candida.
Your prescription will be for fluconazole 400 mg as
a first dose, followed by 100 mg twice daily until you are
pain free for a full week, which usually means at least
two weeks. This seems, on the basis of our experience, a fairly
good guarantee against relapse. If you have nipple pain continue
with the “all purpose nipple ointment” (± gentian
violet and grapefruit seed extract) while you are taking fluconazole.
However, this means that although most mothers require only the
usual two weeks, some need longer treatment. Occasionally it may
take up to seven to ten days for the pain to even start
going away. Call if there is no relief in
seven days. If there is no relief in 10 days, none at all, it is
very unlikely fluconazole is going to be of any help.
It is sometimes useful to treat the baby as well.
The dose for the baby would be 6 mg/kg as a first dose, followed
by 3 mg/kg/day as one dose for the same period of time as the mother.
Note: The mother’s two week prescription
is likely to cost between $300 and $350, though
there is now a generic fluconazole available which is less expensive.
Questions?
see
my book Dr. Jack Newman's Guide to Breastfeeding (called
The
Ultimate Breastfeeding Book of Answers in the USA)
Handout #20 Fluconazole revised January
2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further permission,
on
the condition that it is not used in any context in which
the WHO code on the marketing of breastmilk substitutes is violated
