For this reason, we 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 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.
Fluconazole tends to work best when used in conjunction with probiotics and oral grapefruit seed extract.
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, 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 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. Contact your provider immediately if you have any concerns.
Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the breasts 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.
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. For very resistant cases we have used 100 mg 3x/day for 1 week.