Question: 

Can you get nipple thrush while still pregnant/prior to breastfeeding? If not, what are other causes of dry white patches on nipples while pregnant?

Answered by OB-GYN Karen Carlson, MD: 

White spots on the nipples and the surrounding area during pregnancy may be caused by normal hormone changes, blocked pores and ducts or infections. During pregnancy, a change in the size and number of Montgomery glands is the most common reason to see white spots on the breast. Montgomery glands are located on the nipple and surrounding tissue, and they can become more visible during pregnancy. They can even be seen prior to any other signs of pregnancy. They contain an oily substance that helps keep the nipples soft and supple. The smell of this waxy substance may encourage babies to feed and may help them locate the nipple when first breastfeeding. The Montgomery glands can resemble a pimple, with a white or yellowish head. These spots should not be squeezed or popped, as this can cause infection. They are harmless, and no treatment is necessary. 
 
On the other hand, thrush is a yeast infection. It is usually caused by an overgrowth of the fungus, candida. Candida normally lives on our skin and other areas, and it only becomes a problem when there is an overgrowth. Thrush can occur on the nipples during pregnancy or while breastfeeding. It is more likely to occur when there is a breakdown in the integrity of the skin, like a small cut. Since yeast grows well in dark, moist, warm environments, mouths and nipples are prime places for yeast to overgrow during breastfeeding. Symptoms of thrush are itch, flaky or shiny skin on the nipple or surrounding tissue or red, cracked nipples. Key signs of thrush are sore nipples that last more than a few days, pains that are "shooting" or "burning" or aching deep in the breasts. Pregnancy and nursing can cause your skin to rub against itself in ways that the skin is not used to. Also, some women sweat more during pregnancy. Wearing bras and tops that fit poorly or are not designed for nursing or pregnancy may contribute to thrush by trapping sweat and moisture in the folds of the skin. Heat and humidity where you live can also make thrush infections more common. Taking antibiotics or having a lowered immune system can cause an environment in the body that makes it easier for yeast to grow and cause an infection. Yeast infections in the area of the nipples and the breast are common during breastfeeding, and thrush on the nipples can be persistent and difficult to get rid of. Oftentimes, there is no known cause for thrush.
 
Actions that can help manage or reduce nipple thrush include wearing a clean, washed, cotton bra daily, and using disposable bra pads without waterproof liners. Changing bra pads after each feeding will help keep the nipple dry. If using washable breast pads, boiling them in vinegar water for five minutes after washing may be advised. Additionally, washing clothing and linens on high heat and laundering all shared surfaces that could harbor yeast may help. Ideally, washing these items separately from other clothing and adding bleach or distilled water to the wash is beneficial. Make sure to wash your hands frequently, especially before and after touching your breasts or applying ointments to the breasts. Using a dilute apple cider vinegar solution at a ratio of 1 tablespoon of vinegar to 1 cup of water and applying it to your nipples may help, as long as your nipples aren't cracked or bleeding. Apple cider vinegar is known to have antifungal properties, and it will likely not cause any harm to the skin. 
 
Other things that may help manage nipple thrush are reducing the amount of sugar, cheese, bread, and alcohol in your diet. Adding a probiotic to your diet to restore the balance of yeast and bacteria in your system may help manage thrush as well. Try to keep your breasts clean and dry by rinsing your skin and drying the area around and under your breasts after sweating. After patting the skin dry with a clean towel, you can air dry your breasts or even use a hairdryer on a cool setting. Use a clean towel for each bath or shower, and do not let damp towels hang in bathrooms or kitchen. Consider using paper towels for drying hands. 
 
Initial medical treatment of suspected thrush involves topical antifungal creams (Miconazole or Clotrimazole) applied to the nipples. Residual medicated cream should be removed using olive or coconut oil, prior to nursing. After feeding, the antifungal should be applied again. If the symptoms are not improved, oral antifungal medication (Fluconazole) for 14 days is an alternative. The infant is often treated for oral thrush simultaneously, with oral Nystatin liquid medication that may be prescribed by your health care provider. Four times a day, the liquid medicine is placed in a small cup and used to coat all over the inside of the baby's mouth with a clean finger or cotton swab. This treatment must also be used for at least 14 days. Once treatment beings, there should be an improvement in the first few days. Using topical and oral medications with practical changes to your day-to-day life may be a better treatment than medication alone.