by Jack Newman, MD, FRCPC
Gentian violet (1% solution in water) is still an excellent treatment for Candida Albicans, though we don't suggest mothers use it alone for Candida Albicans (thrush, yeast) because it tends to dry out the nipple and areola. Furthermore, it does not seem to work as well as it used to.
Candida albicans is a fungus that may cause an infection of skin and/or mucous membranes (inside of mouth, for example) in both children and adults. In small children, this yeast is a frequent cause of white patches in the mouth (thrush), or diaper rash.
When the nursing mother has a Candidal infection of the nipple, she may experience severe nipple pain, as well as deep breast pain. Please note: Gentian violet 1% in water also contains alcohol (10% by volume), but the amount of alcohol in the tiny amount of gentian violet you use is of no concern. Apparently some pharmacists are now dissolving it in glycerin, thus avoiding the use of alcohol, but if gentian violet is used as directed baby will get vanishingly small amounts.
Nipple pain caused by Candida albicans
The pain caused by a Candida infection is generally different from the pain caused by poor positioning and/or ineffective suckling. The pain caused by a Candida infection:
• Is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes (such as a poor latch). Burning pain may be due to other causes, however, and pain due to a Candida infection does not necessarily burn.
• Frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes that usually hurts most when the baby latches on, and gradually improves as the baby sucks (unless nipple damage is very severe, in which case the pain may continue throughout the feeding).
• May radiate into the mother's armpit or into her back. This does not mean that the Candida actually is inside the breast or in the ducts. Pain that is felt in a place where there is no cause of the pain, but due to pain elsewhere in the body is called "referred pain." An example is pain in the neck which is actually due to heartburn which may also be felt at the lower end of the breast bone.
• May cause no change in appearance of the mother's nipples or areolas, though there may be redness, or some scaling, or the skin of the areola may be smooth and shiny and the nipple may crack.
• Not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for Candida. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing as may eczema or other skin condition. Also, if the mother's milk supply diminishes, the mother may start having pain later on since babies tend to slip down on the breast when the flow is slow. Another possibility is a new pregnancy, which in itself can cause sore nipples and since the milk production decreases during pregnancy may cause soreness also for that reason.
• May be associated with recent use of antibiotics by the baby or mother, but not necessarily.
• May be quite severe, may or may not be itchy.
• May occur in one breast or nipple only.
• May occur only in the breast. This pain is often described as "shooting", or "burning" in nature, and is often worse after the feeding is over. It is often said to be worse at night. At the same time, the breast appears or feels normal. This is not mastitis since mastitis is associated with a large painful lump in the breast; therefore, there is no reason to treat with antibiotics. On the contrary, antibiotics may make the problem worse.
a) The baby does not have to have thrush in his mouth.
b) A Candida infection of the nipple may be combined with other causes of soreness.
Using Gentian Violet
We believe that gentian violet (combined with "all purpose nipple ointment," see the information sheet Candida Protocol) is a good treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it often works even when used alone (though we don't recommend this, see first paragraph), and relief is rapid.
It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), but not skin. The baby's lips will turn purple, but the purple will disappear after a few days.
Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It's easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%.
1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.
2. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy.
3. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby's cheeks and around his mouth.
4. Dip a clean ear swab (Q-tip) into the gentian violet.
5. Paint one of your nipples and the areola and let dry for a few seconds.
6. Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated.
7. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up that side.
8. Repeat for the other side.
9. If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go.
10. A cotton pad can then be used to wipe the excess gentian violet from baby's face.
11. Repeat the treatment each day for at least three or four days to see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida Protocol information sheet for how long to use gentian violet).
12. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days if necessary.
13. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet, or rinsed in a solution with grapefruit seed extract. Consider stopping artificial nipples. Artificial nipples can interfere with the way the baby latches on and may contribute to your pain.
14. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, only very occasionally seem to be bothered by thrush.
15. Uncommonly, babies who are treated with gentian violet develop sores in the mouth that may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding.
16. It is advisable that a mother with a recurring infection take probiotics orally for a few weeks and or grapefruit seed extract orally for at least 2 weeks. In this case, the baby should probably be treated with probiotics as well (see the Candida Protocol information sheet).
If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of re-infection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. See the Candida Protocol information sheet.
Questions? Get Dr. Jack Newman's book The Ultimate Breastfeeding Book of Answers.
Jack Newman graduated from the University of Toronto medical school as a pediatrician in 1970. He started the first hospital-based breastfeeding clinic in Canada in 1984 at Toronto's Hospital for Sick Children. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa, and has published articles on the subject of breastfeeding in Scientific American and several medical journals. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.
Gentian Violet, Revised 2009©
Written & Revised by Jack Newman, MD, FRCPC 1995-2005©
Revised by Edith Kernerman, IBCLC, & Jack Newman, MD, FRCPC © 2009