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Candida between breasts: The request could not be satisfied

3 Skin problems in women with large breasts—and how to address them

Do skin problems in women with large breasts occur more often? Having ample in the bustline is often valued in our society.  But as with other types of assets, poor management of larger breasts can result in problems. Here are three conditions I treat more in patients who wear larger cup sizes and the stewardship recommended to prevent skin problems.

The problems:

  1. Intertrigo– intertrigo is inflammation and breakdown of the skin barrier in a skin fold.  Skin folds are warmer, damper and experience more friction that non-folded areas of skin.  These conditions can result in a dermatitis much like diaper rash.  Larger breasts create larger folds, such as those between or under breasts, and therefore are more likely to create the conditions for intertrigo. 
  2. Yeast infections– Yeasts are a type of fungal organisms that also tend to like warm and moist body folds.   Two types of yeast infections can occur more commonly when someone has large breasts.  Candidal infections may present with beefy redness and satellite pustules under and between breasts.  A diagnosis of candidiasis is more commonly associated with a history of diabetes and may trigger screening.  Tinea versicolor is another type of yeast infection fond of the oilier areas of the body such as the face, neck, chest, back, as well as the body folds created by breasts.  This type of yeast infection is characterized by pink, brown, and white scaly macules on the infected areas. 
  3. Hyperpigmentation– Larger breasts require more support.  Narrow bra straps on ill-fitting bras sometimes dig into the shoulders causing skin discoloration and dents where the too narrow bra straps rest.

So how does one address the above problems in people with large breasts? 

  1. Yeast infections should be treated with topical or oral antifungal medication, however, they will soon return if the skin conditions that support them are not addressed.  
  2. A new bra: A key component of addressing these skin issues when one has large breasts is to make sure one’s bra fits properly.  Bras that “lift and separate,” as described in the old Playtex “cross your heart” advertisement do more than create a particular silhouette.  Lifting and separating the breasts reduces the skin fold and prevents the development of the friction and dampness that cause these problems.  Although push up bras may be popular, they are not a good idea for everyday if one suffers with intertrigo and yeast infections as they create deeper folds.      
  3. bra liners, cushions and slings: Sometimes women who sweat more need additional relief from a bra liners that wicks the moisture away from the skin.  Comfortslings® which are designed to be worn without a bra, even while sleeping, can also be helpful in recovering from intertrigo and yeast infections as they pull the breasts apart, exposing the skin folds which prevents friction and dampness. If the problem is bra straps digging into the skin, strap cushions may be needed for additional protection and support. 

Are you ready to make a virtual or in-person appointment about a skin problem on the breasts or elsewhere? Schedule one here.

Learn more: Dr. Strachan slide show on skin fungal infections for Medscape

Note:  Some links in this post may result in us benefitting from a third-party sale. 

Tagged with: bosom, bras, breast health, breasts, dermatologist, dermatologist manhattan, dermatologist nyc, intertrigo, rashes, skin care, underwear, women’s health

Posted in: General Dermatology, Uncategorized

What Is Under My Breast?

A 68-year-old woman presented with a 6-week history of a persistent rash that had appeared simultaneously beneath both breasts. She described the rash as feeling moderately itchy and stated that it had not spread beyond the submammary folds. She had a history of type 2 diabetes and hypertension, for which she was taking metformin and lisinopril, respectively. She was treating her rash with an over-the-counter topical cream and powder, but received no relief in symptoms. Recent blood tests were reviewed and appeared to be within the normal limits.

Upon examination, the rashes were erythematous and scaly with satellite lesions (Figures).They were present beneath each breast and extended no further than the skin covered by the overhanging appendages. We took a scraping and biopsy, and we asked her to return for a follow-up appointment in 2 weeks.

Based on the photographs and the case description, what is your diagnosis? 

A. Candidiasis              C. Allergic contact dermatitis

B. Inverse psoriasis     D. Intertrigo

Answer and Discussion on next page

Diagnosis: Candidiasis (A)

Discussion 

Candidiasis is a fungal infection caused by yeasts belonging to the genus Candida. Candida albicans (C albicans) is the most common of the more than 20 species of Candida yeasts that may cause infection in humans.1,2 We did not perform a culture to test for C albicans specifically in our case patient, but we see this condition frequently in our practice, so we highly suspected it to be the causative agent. Most Candida species are commensal and are part of the normal flora in the skin, mouth, vagina, and other mucosal areas of the body; however, it is also an opportunistic pathogen.3 Infection tends to occur in immunocompromised individuals, or when competing microbes are removed, such as after a course of antibiotics.3 Overgrowth of Candida may occur in both of these instances, causing symptoms to develop. Immunocompromised persons, newborns, and adults older than age 65 years are the most susceptible to candidal colonization.4

Candidiasis is one of the oldest and most common dermatological diagnoses, but the increasing prevalence of local and systemic diseases caused by Candida has resulted in numerous new clinical syndromes, the presentation of which depends largely on the individual host’s immune system. 4Candida can cause infection to the skin, gastrointestinal tract, genitourinary area, respiratory tract, and other areas. Some of the most common locations for presentation are the skin, oral cavities, esophagus, and the vaginal canal.1,2,5 In the fourth century BC, Hippocrates was the first to recognize oropharyngeal candidiasis, also called thrush.1 This manifestation of candidiasis is common in older adults, as the risk factors include wearing dentures, diabetes mellitus, and exposure to broad-spectrum antibiotics.6Candida infection of the vaginal canal is also called vulvovaginal candidiasis, also known by the names vaginitis or the common “yeast infection,” which is estimated to occur in nearly 75% of all women during their lifetime.6

The clinical presentation varies on an individualized basis according to the type of infection and degree of immunosuppresion, but generally symptoms of candidiasis range from mild discomfort to inflammation to intense itching. In rare cases, usually in immunocompromised individuals, systemic infection with Candida has been reported.1,6 Cutaneous manifestations of Candida are often described as erythematous, beefy plaques with satellite papules.2,5 The warm, moist areas beneath the arms, the submammary folds, and the groin are common areas for presentation. A diagnosis of candidiasis can be strongly suspected upon visual examination, but a definitive diagnosis requires
biopsy confirmation.

Pathology Findings 
In cases of cutaneous candidiasis, skin scrapings can be examined for budding yeast cells, hyphae (long, branching filamentous structures of fungus), or pseudohyphae, which are distinguished from hyphae by their method of growth, relative frailty, and lack of cytoplasmic connection between cells.4 A solution of potassium hydroxide can be used to dissolve the skin cells, leaving the typical pseudohyphae easily visualized. 2,5 In our case patient, a skin scraping demonstrated pseudohyphae and the clear presence of fungi.

Approaches to Treatment 
Treatment of Candida infections vary on an individual basis, depending on the location of infection, the patient’s underlying diseases, and other factors.4 The most common treatment for cutaneous infections is topical antifungals, most often ketoconazole.

We prescribed topical ketoconazole and a week of fluconazole 200 mg daily to our patient. At the 4-week follow-up, her rash had almost fully resolved and she remained clear of any relapses.

Ruling Out the Other Diagnoses 

What follows is a discussion of some of the other possible diagnoses, which were ruled out for our case patient. 

Inverse Psoriasis 
The cause of psoriasis is not well understood, but it is commonly thought to be either an immune modulation dysfunction or an unregulated growth of epidermal skin cells. 5-7 Psoriasis presents as inflamed red patches, usually with silvery scales reflecting an accumulation of excess skin.5 One of the five major types of psoriasis is inverse psoriasis, which is differentiated by the presence of these lesions almost exclusively located on flexural areas of the body, such as the axillae, breasts, or groin.7 The condition is thought to be exacerbated by the moist environment in these locations of overlapping skin. It is not contagious but can be inherited and aggravated by many factors. Diagnosis is often made by visual inspection, but a biopsy can be used to confirm it. 

Allergic Contact Dermatitis
Allergic contact dermatitis presents with many of the same symptoms that presented in our case patient. This form of dermatitis, a delayed hypersensitivity reaction, is less commonly seen than irritant contact dermatitis.5,6 It results from two phases: (1) the initial induction phase, in which the allergen is picked up by dendrites and presents the allergen to T-cells; and (2) the elicitation phase, in which the previously stimulated T-cells respond by releasing large quantities of cytokines. 5,6,8 It typically presents as an itchy rash or lesion that may also ooze, crust, or become scaly. If the allergen is present chronically, the skin may even darken and thicken. This dermatitis is distinguishable from the irritant form by being more widespread and by being reproducible upon exposure to the allergen.5 Diagnosis is commonly made by the patient’s history and a physical examination, but a patch allergy test is definitive.9

Intertrigo
Intertrigo (intertriginous dermatitis) is an inflammatory rash found on many of the same areas of the body as inverse psoriasis.6 The condition is induced by heat, moisture, friction, or lack of air circulation, commonly in compromised areas of skin where chaffing can occur, such as the groin, axillae, and between the fingers and toes.1,6,10 It can be worsened or colonized by infection, which is commonly candidal, but can also be fungal, bacterial, or viral. 10 It appears as an erythematous, raised, raw-looking rash that can be itchy or seep a clear liquid. There are higher incidents of intertrigo in obese, diabetic, or bedridden adults and in adults who wear diapers.1 Intertrigo is diagnosed with a combination of potassium hydroxide stains, Wood’s lamp inspection, skin biopsy, and visual identification.6,11

References

1. Ramos-E-Silva M, Lima CM, Schechtman RC, Trope BM, Carneiro S. Superficial mycoses in immunodepressed patients (AIDS). Clin Dermatol. 2010;28(2):217-225.

2. Shiraki Y, Ishibashi Y, Hiruma M, Nishikawa A, Ikeda S. Candida albicans abrogates the expression of interferon-gamma-inducible protein-10 in human keratinocytes. FEMS Immunol Med Microbiol. 2008;54(1):122-128.

3. Rosenbach A, Dignard D, Pierce JV, Whiteway M, Kumamoto CA. Adaptation of Candida albicans for growth of the mammalian intestinal tract. Eukaryot Cell. 2010;9(7):1075-1086. 

4. Hidalgo JA. Candidiasis. http://emedicine.medscape.com/article/213853-overview#a0101. Updated May 21, 2012. Accessed February 1, 2013.

5. Gibney MD, Siegfried EC. Cutaneous congenital candidiasis: a case report. Pediatr Dermatol. 1995;12(4):359-363.

6. Hoppe JE. Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal. Pediatr Infect Dis J. 1997;16(9):885-894.

7. PubMed Health. Psoriasis. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470. Accessed February 1, 2013.

8. Hogan DJ. Allergic contact dermatitis. http://emedicine.medscape.com/article/1049216-overview#a0104. Updated September 14, 2011. Accessed February 1, 2013. 

9. Hogan DJ. Allergic contact dermatitis clinical presentation. http://emedicine.medscape.com/article/1049216-clinical. Updated September 14, 2011. Accessed February 1, 2013.

10. Centers for Disease Control and Prevention. Genital/vulvovaginal candidiasis. www.cdc.gov/fungal/Candidiasis/genital. Updated February 27, 2012. Accessed February 1, 2013.

11. Selden ST. Intertrigo. http://emedicine.medscape.com/article/1087691-overview. Updated March 27, 2012. Accessed February 1, 2013. 


The authors report no relevant financial relationships.

Ringworm or Candida: What’s the Difference?

It can begin as a small sore, scaly skin, or a rash. Then it often spreads, itches, or burns.

If you’re experiencing any of these symptoms, you may have a fungal infection. The infections can affect anyone, but if you (or your children) play sports or are engaged regularly in other physical activities, your chance of contracting these is higher.

”Fungus is everywhere,” says Jeffrey Weinberg, MD, associate clinical professor of dermatology at Columbia University College of Physicians and Surgeons.

“It’s not just in the gym,” he says. It’s there, of course, but it’s also in school locker rooms, fine hotels, your house, and other places.

Knowing how to recognize a potential fungal skin infection early and what to do about it can minimize your misery.

Even if you’re just an everyday exerciser or a junior varsity member, you can take notes from the competitive athlete community. In 2010, the National Athletic Trainers’ Association (NATA) issued its guidelines for skin disease prevention, including fungal infections.

It did so because of the number of outbreaks involving skin diseases, including fungal infections, among competitive athletes. More than half of all infectious disease outbreaks in competitive sports, from 1922 through 2004, involved skin diseases, the association found.

The NATA guidelines are aimed at reducing that toll. What works for them can also work for you.

WebMD also asked two dermatology experts for an update on what you should know about fungal skin infections. We zeroed in on two common culprits causing fungal skin infections — ringworm and Candida. Here’s what we found out.

Ringworm and Candida: What’s the Difference?

Both types of infection are fungal, says Linda Stein Gold, MD, director of dermatology at Henry Ford Hospital in Detroit. At their root are fungi, not the bacteria or viruses that cause other infections.

Technically speaking, “ringworm is a dermatophyte,” says Weinberg. A dermatophyte is simply a type of fungi that can cause skin, hair, or nail infections.

“Candida is a yeast,” says Weinberg. These fungi can cause infections on many areas of the body.

These fungal infections affect some of the same body parts but also different ones, Stein Gold tells WebMD. The appearance of the infections can differ, too.

Ringworm Facts

Ringworm infections don’t involve worms, of course. These fungi are responsible for:

  • Athlete’s foot, or tinea pedis
  • Jock itch, also called tinea cruris
  • Infections on the scalp and hair, or tinea capitis
  • Nail infections
  • Infections on the legs, arms, and trunk

You will usually notice itching. “When it starts out, it can be itchy and burning,” Stein Gold says of ringworm infections. There can be a ring-shaped rash. The center might be red, also, or could be normal skin color.

If on the scalp, this fungus can cause hair loss.

There can be scaly patches and inflammation.

Fungal infections sometimes attack the feet, between the toes. It can look ”mushy,” says Weinberg. Or, it can live on the side of the feet, giving the foot a moccasin type look, he says. Weinberg reports formerly serving as an investigator for Ortho Dermatologics.

The infection can be spread from another infected person, an object with fungi on it (such as a towel), or even your household pet.

Candida Facts

Yeast infections, commonly caused by a group of fungi from the species Candida, can also affect many body parts. These organisms can cause infections when there is overgrowth. These infections can occur at many sites, including:

  • The vagina
  • The mouth, called oral thrush
  • Skin, especially under skin folds such as under the breasts
  • Nail beds
  • Warm moist areas, such as the underarms

Women with a vaginal yeast infection often report a white, cheesy discharge. In the mouth, the infection shows up as thick, white lacy patches on the tongue.

On the skin, the infections are often a red, flat rash with scalloped edges. There are ”satellite” lesions nearby, Weinberg says. There can be pustules.

Men can be affected with yeast infections in the scrotum, Weinberg says. This infection often shows up as bumps.

Fungal Infection Treatments

Topical antifungal creams and lotions are often used, say Stein Gold and Weinberg. Some are over the counter, such as:

Often the same topical medicine will work for ringworm and yeast, Stein Gold tells WebMD. There’s usually no harm in trying over-the-counter remedies first for uncomplicated skin infections, she says. “If you use one of these OTC products for a few weeks and it’s not better, I’d certainly have it looked at,” Stein Gold says.

If the infection is extensive or persistent, you may need prescription medicines to treat it. Among these are prescription topicals such as ciclopirox (Loprox, Penlac), ketoconazole (Nizoral), and oxiconazole (Oxistat).

Oral antifungal medicines that may be prescribed include:

How long you take these medicines depends in part on how bad the infection is. Often, it is just a matter of weeks, Stein Gold says.

Nail infections may take longer to clear up than infections elsewhere, she says. For toenails, she says, three months of treatment is common. For fingernails, six weeks may be needed.

Prompt treatment is always a good idea, Stein Gold says. “Try to treat it early so it doesn’t spread,” she says. “Pay attention if you have burning, itching.”

If you have an underlying chronic medical condition, especially one that involves a suppressed immune system, it’s crucial to treat earlier than later.

Preventing Fungal Infections

You can follow some simple steps to reduce the risk of these fungal infections — or avoid a repeat, doctors say. Here are some prevention tips from the National Athletic Trainers’ Association:

  • Keep the skin dry. “That really helps,” says Stein Gold. Fungi love warm, moist areas.
  • Take your own instruments (available at beauty supply stores) to the nail salon. Be sure to sterilize the instruments between manicures and pedicures.
  • Protect your nails. Doctors warn against cutting the cuticle or pushing it back too much. “It’s there to protect the nail from outside invasion,” Stein Gold says.
  • Baby your feet. Wear white cotton socks. Some socks are made of ”wicking” material to reduce moisture.
  • Start fresh. If you’ve had a bad athlete’s foot infection, toss your flip flops or shower shoes and replace them with a new, clean pair.
  • Use foot powders if the fungi love your feet. “Keep your feet dry and cool,” Weinberg says.

Wash your workout clothes. Repeat wearing invites fungus. The same goes for socks, swimsuits, and sweaty T-shirts. Wear once, wash, repeat.

Treating Yeast While Breastfeeding – Conditions We Treat – UR Medicine Breastfeeding & Lactation Services – Rochester, NY

Yeast (also called thrush or Candida) is a fungus that grows in warm, dark, moist environments, like the linings of the mouth and vagina, the diaper area, skin folds, bra padding, and on nipples that are frequently wet.


You may have breast yeast if you have:


  • Constant nipple pain in the early weeks of breastfeeding.
  • Nipple pain that starts after breastfeeding is going well and hasn’t been painful.
  • Itchy or burning nipples that look pink or red, shiny, or flaky. Nipples can also look normal.
  • Cracked nipples.
  • Shooting pains deep in your breast during or after you nurse or pump.
  • Intense nipple or breast pain that doesn’t get better with better latch-on and positioning.
  • You are taking, or have just finished taking, antibiotics. Yeast infections are common following antibiotic treatment.
  • You have a vaginal yeast infection.
  • You’ve been told your baby has oral thrush (thick, white patches in his/her mouth) and/or a yeasty diaper rash.

Nipples with any sort of rash should be seen right away by your doctor. It could be a sign of another problem that needs treatment. Your doctor may take a cotton swab of your nipple area and send it to a lab for testing.


Medical Treatment


Yeast can be difficult to treat and is easily spread. Because of this, if you or your baby is diagnosed with yeast it is very important for both of you to be treated.


If Your Baby is in the Hospital


If you’re told your baby has yeast he/she will be treated with either a liquid medicine in their mouth called Nystatin (if yeast is found in their mouth) or an anti-fungal skin cream (if yeast is found on their skin). 


  • If the yeast infection is causing shooting or stabbing pains deep in your breast, it may be in your milk ducts, too. The best treatment for this is pills that must be prescribed by your doctor.
  • If yeast is NOT deep in breasts and only on your nipples, then you can use an over-the-counter anti-fungal skin cream. Again, check with your doctor for instructions.
  • Treatment should last at least 1-2 weeks after you (and your baby) feel all better to make sure it is gone.

What Can I Do?


There are other things you can do to help with yeast…


Hygiene


  • Change or wash anything that comes in direct contact with your nipples (bras, bra pads, towels, etc.) in hot water with bleach daily. Dry on hot setting in the dryer.
  • Use disposable breast pads until you are done using all medicines.
  • Wash any pump parts that come in contact with the skin or milk in warm soapy water after each use. You can:
    • Boil the parts for 20 minutes
    • wash the parts in the dishwasher on high heat setting, or
    • sterilize the parts using microwave steam bags.
Diet


  • “Good” bacteria helps fend of the “bad” bacteria that cause yeast. Add some “good” bacteria to your diet with yogurt or supplements called probiotics that contain lactobacillus acidophilus.
  • Sugar feeds the fungus and can make it worse! Limit the amount of yeast and sugar in your diet. This means cutting down on sugary foods, cheeses, breads, and alcohol.

Can I feed the baby this milk? 


Yes: While you are using medicines for yeast your fresh, refrigerated, or frozen pumped breast milk can be used safely for your baby.


Freezing temporarily “shuts off” the yeast, but does not kill it. Be sure to label all milk that you’ve pumped during if you or your baby has thrush/yeast. Your baby’s doctor will decide if it is safe to use.


For questions or more information, your doctor or your baby’s doctor can call the Lactation Study Center (585) 275-0088.


For outpatient help, call the UR Medicine Breastfeeding & Lactation Services at (585) 276-MILK.






Yeast Breast Rash / Infection: Diagnosing and Treating

 

Impetigo is a skin infection and usually looks red with a dried crusty honey colored discharge. It tends to spread. The usual treatment is an antibiotic cream such as BACTROBAN. For severe cases, I will also use an oral antibiotic.

I commend you for choosing to breastfeed and sticking with it. Your baby will be much healthier as a result. I am sorry that your doctor is so negative. When I don’t agree with a patient’s philosophy, I try to just be quiet – not antagonistic… YES, YOU CAN CONTINUE BREASTFEEDING, even with a breast rash.

[rp4wp]

What you really need to do is find a good certified Lactation Consultant to help you diagnose your rash. It is difficult to tell you what it is via e-mail, but it is very possible that it is a yeast problem. Here is some information about yeast on the breasts:

Candida (Yeast or Thrush) Infection on Nipples

Candida (also called yeast, monilla or thrush) is a fungus that thrives in warm, dark, moist environments, such as the mucus membranes of the mouth and vagina, the diaper area, skin folds, bra pads, and on persistently wet nipples.

Suspect candida as the cause of your sore nipples if:

  • Your nipples are extremely sore, burning, itching, red, or blistery.
  • You experience shooting pains in your breasts during or just after feeding (especially during your milk ejection reflex).
  • The usual remedies for sore nipples aren’t working.
  • Baby has oral thrush (white, cottage-cheese-like patches on the tongue and sides of the mouth) and/or a yeasty diaper rash.
  • Your nipples suddenly become sore after a period of pain-free breastfeeding.
  • You are taking, or have just finished taking, a course of antibiotics. Yeast infections are common following antibiotic treatment.

Here are some simple suggestions that may help prevent a yeast infection on your nipples, or cure a mild case of yeast infection, or what you are describing as a breast rash:

  • Yeast organisms hate sunlight, so give your bra and breasts a sun bath. Expose your nipples to sunlight for several minutes several times a day. After washing them, dry your bras in the sunlight.
  • Air-dry your nipples after each feeding
  • Avoid plastic-lined breast pads that irritate skin and trap leaked milk.
  • Change nursing pads after each feeding.
  • Wear 100 percent cotton bras and wash them daily in very hot water.
  • Thoroughly wash pump parts that come in contact with your breasts in a bleach solution and boil them in water for five minutes daily.

Treating Breast Rash Candida: Infection of the Nipple

If the simple home remedies listed above don’t bring relief, consult your healthcare provider about the following treatments:

  • Apply an antifungal cream (mycostatin, clotrimazole, myconazole) to your nipples as suggested or prescribed by your doctor.
  • If you have a candida infection in your nipples, baby should be treated for thrush even if you can’t see any white patches in the mouth. Your healthcare provider will prescribe an oral antifungal suspension that should be painted on baby’s tongue, roof, and sides of the mouth three or four times a day for a couple of weeks.
  • If baby has a candida diaper rash, treat it with an over-the-counter antifungal cream.
  • Eat lots of yogurt (the kind with live active cultures) and take oral acidophilus. This encourages good bacteria to live in your gut and discourages the growth of yeast.
  • If your baby has thrush but your nipples are not yet sore, apply the prescribed medicine to baby’s mouth just before feeding so that your nipples get the preventive benefit of the medication as well.
  • If your healthcare provider advises you to wash the creams off your nipples prior to breastfeeding, do so gently with warm water.
  • While nursing on a candida-infected nipple can be extremely painful, it is necessary to keep the affected breast empty to prevent mastitis, or even a candida infection deeper into the breast tissue. Pay particular attention to proper latch-on and easing your baby off your nipples at the end of the feeding, since infected nipples are more sensitive and prone to injury from improper sucking patterns.

Yeast infections can be very persistent. Use the full course of medication suggested by your doctor, and continue using the home remedies for several weeks so that the breast rash / infection will not reoccur. Click here for more information on treating sore nipples.

Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans | International Breastfeeding Journal

The cases were breastfeeding women with self-reported symptoms that are anecdotally related to Candida albicans infection of the breast: radiating, burning and penetrating or non-penetrating breast pain with or without associated nipple pain during or after breastfeeding. These symptoms may or may not be accompanied by vivid pink dry, scaling, thinning or shiny skin on the nipple and areola. The controls were breastfeeding women who did not have any of these symptoms. All infants were exclusively or partially breastfed, no limitation for the age of the infant was applied.

Sample size calculation

The literature shows a wide variation in the presence of Candida albicans in breast milk and in order to allow a sample size calculation it was hypothesised, based on previous studies, that there should be a 33% higher occurrence of Candida albicans in the breast milk of women with symptoms traditionally associated with Candida albicans infection than in the breast milk from women without symptoms. Based on α = 0.05 and β = 0.2 with a difference of 33% between the groups the sample size was determined as 35 × 2.

Study setting

The study took place at a breastfeeding clinic attached to an Obstetrics and Gynaecology Unit at a district hospital in southern Sweden. The breastfeeding clinic was started in 1992 and is situated in a town without particular socioeconomical problems. Today, four midwives with long experience of breastfeeding and its problems manage the clinic. Three of the four midwives have completed university courses on breastfeeding and two of the four have passed the IBCLC examination (International Board Certified Lactation Consultant). Breastfeeding women can contact the clinic for telephone guidance or to book a time for a consultation. In the hospital up-take area there are 46 well-baby clinics and of these, three took part in the study by identifying women without symptoms and who were prepared to take part in the study as the control group. The control group was also partially recruited from the hospital unit where postpartum consultations are carried out.

Sample, recruitment and study population

For inclusion in either group women were required to be healthy, to understand spoken and written Swedish and to be currently breastfeeding either partially or exclusively. For inclusion in the case group women either consulted the breastfeeding clinic or were referred there by other care providers because of problems with radiating, burning and penetrating or non-penetrating breast pain with or without nipple pain during or after breastfeeding. These symptoms could be accompanied by pink dry, scaling, thinning or shiny skin on the nipple and areola but skin changes were not criteria for inclusion. Women who had pain or nipple damage that were diagnosed by the attending midwife as being caused by breastfeeding technique problems or mastitis were excluded, as were women who had skin symptoms that were diagnosed as eczema. Women in the control group were required to have no pain and normal nipple appearance.

The final sample consisted of 35 women in the case group and 35 women in the control group. A total of 11 women were excluded from participation in each of the groups because they did not meet the inclusion criteria, they refused to partake or there were logistic problems in finding appointment times that suited them.

Material and data collection

Data were collected between March 2014 and March 2017. After informed consent had been acquired, each individual was asked questions about background variables; mothers’ and infant’s age, mother’s parity, type of birth, history of gestational diabetes or type 1 diabetes, history of vaginal Candida albicans or breast Candida albicans infections, previous breastfeeding and intake of antibiotics during or after birth. The women with symptoms were asked to localise their pain: “mostly in the nipple”, “mostly in the breast” or “equally in both nipple and breast”. They were asked to gauge their pain on a plastic slide-rule with numbers on one side and smiley or sad faces on the other side. The numbers ranged from 0 = no pain to 10 = unbearable pain both during and after breastfeeding. A five-grade scale was used to measure to what extent the mothers felt that their pain interfered with breastfeeding: 1 = no interference to 5 = extreme interference. The women were asked to describe the symptoms of pain they experienced in both the breast(s) and the nipple(s): radiating, non-radiating, burning, non-burning and penetrating or non-penetrating pain. Symptoms from the nipples were described as burning or dry scaling skin on the nipple and areola, vivid pink, thinning or shiny nipple and areola tissue and participants were asked to answer “yes” or “no” for each of these descriptions of nipple appearance.

At recruitment, a sample of breast milk was given by all the participants, both case and control groups. Breast milk was collected from the most painful breast in the case group and from either breast in the control group. The women used clean medical gloves to hand express approximately one millilitre of breast milk, which was then discarded. The next step was cleansing of the nipple and aereola with sterile gauze drenched in sterile sodium chloride (9 mg/ml) followed by application of an electrical breast pump to extract approximately two millilitres of breast milk. All loose components of the breast pump were sterile and disposable as were the 10 ml test tubes that were used to collect the milk. Samples from the control group were transported to the university hospital laboratory in special cold bags containing ice. Samples from the case group were immediately placed in a refrigerator at + 5 °C. All samples reached the laboratory within 30 min after sampling and were from there transported at minus 20 °C for analysis at the microbiological unit at a nearby university hospital. The samples were cultivated on Sabouraud Agar and CHROM Agar Candida for five days at 30 °C and analyses carried out for Candida spp. Results of the cultivation were given simply as “positive” or “negative” and the species type was identified. The milk samples have been retained in biobank BD47 at − 20 °C where they will remain until the results of the study have been published.

The Breastfeeding Self-Efficacy Scale (Short Form) [13] comprising 14 statements answerable on a 5-point Likert scale was administered to all participants at recruitment. The items on the scale all begin with the statement “I can always.. .” and the extremes of the 5-point scale are: 1 = not at all confident and 5 = always confident. The range of possible total scores on the BFSES -SF is 14–70.

Women in the control group received a follow-up questionnaire by email at four weeks after the first contact. They were asked if they had had symptoms connected to perceived Candida overgrowth during the last four weeks including breast and/or nipple pain under and after breastfeeding measured from 0 to 10 where 0 = no pain and 10 = unbearable pain. They were also asked to indicate whether they continued to breastfeed; exclusively, partially or not at all. The participants in the case group answered a telephone questionnaire at four weeks after the first contact. The questions were the same as those posed to the control group.

Statistical analyses

Data were analysed using SPSS version 22. The case and control groups were compared for background variables; mothers’ age, educational level, parity, history of diabetes, Candida infection in pregnancy and previous breastfeeding, use of antibiotics during and after birth and infants age. The case group was divided into those whose breast milk showed a growth of Candida albicans and those whose milk did not show a growth of Candida albicans. These two groups were then compared for differences in type of breast symptoms. Primiparous and multiparous mothers in the case and control groups were compared for scores for items on the BSES –SF and for total scores. For comparisons of continuous variables, the student’s t-test was used and for all other variables Pearson’s Chi-2 test (Fisher’s exact test, where appropriate) were used. The primary hypothesis was tested using Fisher’s exact test.

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Thrush during breastfeeding – expert answers, online doctor consultation

Where else can you find thrush? (Thrush of the mammary glands during breastfeeding)

The problem was not expected from . ..

Every woman, having given birth to a child, thinks that all the most “terrible” is over. Yes, thoughts about the health of the unborn child and about the birth itself are really hard, but after childbirth, many mothers can meet with such a disease as thrush of the mammary glands while breastfeeding.This type of candidiasis is quite rare compared to vaginal. But it also has its own niche in the section with diseases that require special attention, since when breastfeeding there is a danger of transmitting thrush to the baby.

What is it?

So, thrush is a disease caused by overgrowth of colonies of fungi of the genus Candida albicans. Normally, they are found on the skin and mucous membranes of the mouth, intestines, and vagina. The growth of this fungus is controlled by other microorganisms that must also be present to maintain microflora balance.But there are situations when this is impossible. For a number of reasons, immunity is reduced or hormonal imbalance occurs. The consequence of all is the uncontrollable growth of some bacteria and the death of others.

Causes of thrush when breastfeeding:

– Taking antibiotics. These medicines kill bacteria that protect the body from the rapid growth of fungus.

– Taking hormonal contraceptives. So some hormones and imbalances in this area can contribute to the widespread spread of fungal infection.This also includes those homronic rearrangements that the female body undergoes after childbirth (resumption of the menstrual cycle, lactation)

– Breaking the diet of a nursing woman: excessive consumption of “fast” carbohydrates (buns, sweet), fried, salty.

– Contact infection: when a mother receives this disease from a baby suffering from stomatitis or a situation when a mother transfers an infection to her breasts (nipples) from the vagina

– Violation of personal hygiene rules.Often, if the basic canons of cleanliness are not observed, due to certain circumstances, candida skin lesions appear. This can happen under the breast, especially if milk is leaking in the crease or if bras are not fitted or used correctly. Also, when breastfeeding, cracks in the nipples are common, which only increase the likelihood of infection.

It is worth noting that a woman during pregnancy and lactation becomes very vulnerable to all kinds of infections, since nature has laid down a natural decrease in the immune response.Therefore, from the first day when you learned about the connection between yourself and the child until the last moment, while you are breastfeeding, mom should take care of herself.

Symptoms.

Many mothers often endure all the manifestations of candidiasis, associating them with improper attachment of the baby to the breast, sometimes there is simply not enough time for herself, because, of course, her baby is the most important thing. Nevertheless, it is important to know only 4 symptoms of , signaling that it is time to see a doctor and start treatment before the child becomes infected:

-Nipples become bright red or bright pink, swell a little.Small bubbles may form on them.

– Itching appears in the nipple area.

-One of the main manifestations is pain during feeding, which intensifies after finishing. The pain can also be on the nipples themselves or spread throughout the mammary gland, shooting, sometimes burning in nature. In addition to severe pain, it is not uncommon to have an increase in the sensitivity of the nipples, even light touches of clothing can cause painful sensations.

– Often a decrease in milk production.

Who should you contact if you suspect breast thrush?

After you find yourself having problems, you should immediately consult a gynecologist. He will differentiate between psoriasis, mastitis, herpes and other diseases, and take a nipple scraping for microscopic examination. After the diagnosis is confirmed, you can safely start treating it.

What to do if there is a yeast infection on the mammary glands?

Treatment of thrush is a rather difficult and lengthy process.Oral medication is only prescribed in extreme cases when chest pain becomes unbearable. The difficulties of treatment lie in the fact that in addition to applying the drug to the chest, it is necessary to adhere to several rules for effective therapy. In addition, the treatment should be for both the mother and the child (even in the case of apparent health). Otherwise, having treated one of them, the thrush will recur.

For local treatment, creams and ointments are used, the main active ingredients of which are Nystatin, Natamycin, Clotrimazole and others.Pimafucin cream, Candide cream, Nizoral are often used in treatment. Creams are applied to clean skin 2-3 times a day. Before feeding, you must thoroughly rinse the drug from the nipples. In between, you can also treat with Purelan ointment – it will accelerate the healing of cracks. After each feeding, you should wash the nipples with a solution of soda (at the rate of 1 teaspoon per glass of water) or you can use the advice of traditional medicine (use of herbal decoctions, honey, sea buckthorn oil, etc.)

It is extremely important to adhere to 5 rules when treating breast thrush:

-After each contact with the breast or after using the toilet, after changing diapers or after the next wellness procedures, you should always wash your hands with soap and water so that the fungus does not spread to the already healed surface.You also need to thoroughly clean all devices that are used to express milk (breast pump, breast pads), baby’s nipples.

– The underwear you wear must be cotton. It will not be superfluous to organize air baths for 2-3 hours. Keep the skin of the breasts and nipples clean and dry. It is worth giving up breast pads.

– Frequent latching of the baby to the breast during short-term feeding will reduce inflammation. If the pain is completely unbearable, you can express.Do not freeze expressed milk, give immediately.

– A strict diet should be adhered to (exclude the use of sweets and foods containing yeast). You can supplement your diet with probiotics – bifidum bacterin, lactobacterin. Yogurt alone in the treatment of this pathology will not be enough.

-In case of “cheesy” discharge from the genital tract, you should consult a gynecologist and also start treatment.

Symptoms such as tenderness and nipple pain can be relieved by applying ice cubes made from herbal teas or boiled water.If all the points of treatment are observed, relief already occurs on the 2-3 day of processing the mammary glands. All doctor’s prescriptions must be strictly followed. Treatment of infants is reduced to lubricating their mouths with solutions of herbs, sea buckthorn oil, honey, soda solution, Hexoral. With the external manifestation of stomatitis, that is, the detection of fungi in the corners of the mouth and around the red border of the lips, they are also treated with creams in both the mother and the child. Mom should pay attention to immunity – if possible, rest more often, eat right.It will not be superfluous for breast thrush to take immunomodulators, for example, Genferon light.

How does thrush affect breastfeeding?

Often, due to the sensation of pain, milk production decreases. The quality of milk may also suffer due to the addition of mastitis, since the colonies of the fungus clog the ducts and the milk stagnates. In addition, the fungus is easily transmitted to the baby, which, in case of infection, will not fully support the sucking process due to pain in its mouth – it will become restless.In a baby, you can see a white coating on the mucous membrane of the cheeks, throat and tongue. If there is no result of treatment within 48 hours, you should consult a doctor in order to replace therapy.

Respectfully yours, Minasyan Margarita Gegamovna.

Source: http://www.molochnica.su/pri-gv/grudnyh-zhelyoz-pri-grudnom-vskarmlivanii

FLUKONAZOL RENEVAL 0.15 N1 CAPS

Single or multiple use of fluconazole at a dose of 50 mg does not affect the metabolism of phenazone (Antipyrin) when used simultaneously.

The simultaneous use of fluconazole with the following drugs is contraindicated:

Cisapride: with the simultaneous use of fluconazole and cisapride, adverse reactions from the heart are possible, including ventricular tachysystolic arrhythmia of the “pirouette” type (torsade de pointes). The use of fluconazole at a dose of 200 mg 1 time per day and cisapride at a dose of 20 mg 4 times a day leads to a pronounced increase in plasma concentrations of cisapride and an increase in the QT interval on the ECG.The simultaneous use of cisapride and fluconazole is contraindicated.

Terfenadine: with the simultaneous use of azole antifungals and terfenadine, serious arrhythmias may occur as a result of an increase in the QT interval. When taking fluconazole at a dose of 200 mg per day, an increase in the QT interval has not been established, however, the use of fluconazole at doses of 400 mg per day and above causes a significant increase in the concentration of terfenadine in blood plasma. The simultaneous use of fluconazole at doses of 400 mg per day or more with terfenadine is contraindicated

(see section “Contraindications”).Treatment with fluconazole at doses less than 400 mg per day in combination with terfenadine should be closely monitored.

Astemizole: the simultaneous use of fluconazole with astemizole or other drugs, the metabolism of which is carried out by the cytochrome P450 system, may be accompanied by an increase in serum concentrations of these drugs. Elevated plasma concentrations of astemizole can lead to prolongation of the QT interval and

in some cases to the development of arrhythmias of the ventricular tachysystolic type “pirouette” (torsade de pointes).The simultaneous use of astemizole and fluconazole is contraindicated.

Pimozide: despite the fact that there have been no relevant studies in vitro or in vivo, the simultaneous use of fluconazole and pimozide can lead to inhibition of the metabolism of pimozide. In turn, an increase in plasma concentrations of pimozide can lead to a prolongation of the QT interval and, in some cases, to the development of arrhythmias of the ventricular tachysystolic type “pirouette” (torsade de pointes). The simultaneous use of pimozide and fluconazole is contraindicated.

Quinidine: despite the fact that there have been no relevant studies in vitro or in vivo, the simultaneous use of fluconazole and quinidine can also lead to inhibition of quinidine metabolism. The use of quinidine is associated with prolongation of the QT interval and, in some cases, with the development of arrhythmias of the ventricular tachysystolic type “pirouette” (torsade de pointes). The simultaneous use of quinidine and fluconazole is contraindicated.

Erythromycin: the simultaneous use of fluconazole and erythromycin potentially leads to an increased risk of cardiotoxicity (prolongation of the QT interval, torsade de points) and, as a result, sudden cardiac death.Concomitant use of fluconazole and erythromycin is contraindicated.

The following medicinal products are not recommended:

Halofantrine: fluconazole may increase the plasma concentration of halofantrine due to inhibition of the CYP3A4 isoenzyme. Perhaps the development of arrhythmias of the ventricular tachysystolic type “pirouette” (torsade de pointes) when used simultaneously with fluconazole, as well as with other antifungal agents of the azole series, therefore, their combined use is not recommended.

Caution should be exercised when used concomitantly with fluconazole:

Amiodarone: The use of amiodarone has been associated with prolongation of the QT interval. Caution should be exercised with the simultaneous use of fluconazole and amiodarone, especially when taking a high dose of fluconazole (800 mg).

Care should be taken and, possibly, dose adjustments should be made while using the following drugs and fluconazole:

• Drugs affecting fluconazole:

Hydrochlorothiazide: repeated use of hydrochlorothiazide concurrently with an increase in fluconazole concentration leads to blood plasma at

40%.The effect of this degree of severity does not require a change in the dosage regimen of fluconazole in patients receiving diuretics at the same time, but the doctor should take this into account.

Rifampicin: Concomitant use of fluconazole and rifampicin results in a 25% decrease in the area under the concentration-time curve (AUC) and a 20% elimination half-life of fluconazole. In patients taking rifampicin at the same time, it is necessary to consider the advisability of increasing the dose of fluconazole.

• Drugs affected by fluconazole:

Fluconazole is a moderate inhibitor of cytochrome P450 isoenzymes 2C9 and 3A4 (CYP). Fluconazole is also an inhibitor of the CYP2C19 isoenzyme. In addition, in addition to the effects listed below, there is a risk of an increase in plasma concentrations of other drugs metabolized by isoenzymes CYP2C9, CYP2C19 and CYP3A4 when used concomitantly with fluconazole. In this regard, caution should be exercised with the simultaneous use of the listed drugs, and if necessary, such combinations, patients should be under close medical supervision.It should be borne in mind that the inhibitory effect of fluconazole persists for 4-5 days after discontinuation of the drug due to the long half-life.

Alfentanil: there is a decrease in clearance and volume of distribution, an increase in the half-life of alfentanil. Perhaps this is due to the inhibition of the CYP3A4 isoenzyme by fluconazole. Alfentanil dose adjustment may be required.

Amitriptyline, nortriptyline: increased effect. The concentration of 5-nortriptyline and / or S-amitriptyline can be measured at the beginning of combination therapy with fluconazole and one week after the start of treatment.If necessary, the dose of amitriptyline / nortriptyline should be adjusted.

Amphotericin B: In studies in mice (including those with immunosuppression), the following results were noted: a small additive antifungal effect in systemic infection with C. albicans, no interaction with intracranial infection with Cryptococcus neoformans, and antagonism with systemic infection caused by A. fumigatus. The clinical significance of these results is not clear.

Anticoagulants: like other antifungal agents (azole derivatives), fluconazole, when used simultaneously with warfarin, increases prothrombin time (by 12%), and therefore, bleeding may develop (hematomas, nosebleeds and gastrointestinal tract, hematuria, melena). In patients receiving anticoagulants of the coumarin and indandione series and fluconazole, it is necessary to constantly monitor the prothrombin time during the period of therapy and within 8 days after simultaneous use.You should also evaluate the feasibility of adjusting the dose of these anticoagulants.

Azithromycin: with simultaneous oral administration of fluconazole in a single dose of 800 mg with azithromycin in a single dose of 1200 mg, no pronounced pharmacokinetic interaction between both drugs has been established.

Benzodiazepines (short-acting): after oral administration of midazolam, fluconazole significantly increases the concentration of midazolam and psychomotor effects, and this effect is more pronounced after taking fluconazole by mouth than when using it intravenously.If concomitant therapy with benzodiazepines is necessary, patients taking fluconazole should be monitored to assess the appropriateness of a corresponding reduction in the dose of benzodiazepine.

With the simultaneous use of a single dose of triazolam, fluconazole increases

AUC of triazolam by approximately 50%, Cmax – by 20-32% and the half-life by

25-50% due to inhibition of the metabolism of triazolam. Dose adjustment of triazolam may be necessary.

Carbamazepine: Fluconazole inhibits the metabolism of carbamazepine and increases the serum concentration of carbamazepine by 30%. The risk of developing carbamazepine toxicity must be considered. The need to adjust the dose of carbamazepine depending on the concentration / effect should be assessed.

Calcium channel blockers: some calcium channel antagonists

(nifedipine, isradipine, amlodipine, verapamil and felodipine) are metabolized by the CYP3A4 isoenzyme.Fluconazole increases the systemic exposure of calcium channel antagonists. It is recommended to control the development of side effects.

Nevirapine: Co-administration of fluconazole and nevirapine increases the exposure of nevirapine by approximately 100% compared to the control data for the single use of nevirapine. Due to the risk of increased nevirapine excretion with concomitant drug use, some precautions and close patient monitoring are necessary.

Cyclosporine: In patients with a kidney transplant, the use of fluconazole at a dose of

200 mg per day leads to a slow increase in the concentration of cyclosporine. However, with repeated use of fluconazole at a dose of 100 mg per day, changes in the concentration of cyclosporine in bone marrow recipients were not observed. With the simultaneous use of fluconazole and cyclosporine, it is recommended to control the concentration of cyclosporine in the blood.

Cyclophosphamide: with the simultaneous use of cyclophosphamide and fluconazole, an increase in serum concentrations of bilirubin and creatinine is noted.

This combination is acceptable given the risk of increased concentrations of bilirubin and creatinine.

Fentanyl: One death reported, possibly related

with concomitant use of fentanyl and fluconazole. The disturbances are thought to be related to fentanyl intoxication. It has been shown that fluconazole significantly prolongs the elimination time of fentanyl. It should be borne in mind that an increase in the concentration of fentanyl can lead to respiratory depression.

Inhibitors of HMG-CoA reductase: with the simultaneous use of fluconazole with inhibitors of HMG-CoA reductase, metabolized by the CYP3A4 isoenzyme (such as atorvastatin and simvastatin) or by the CYP2D6 isoenzyme (such as rhabastatin and fludomiopathia), increases the risk of myiopathies (such as rabbit) … If simultaneous therapy with these drugs is necessary, patients should be observed in order to identify symptoms of myopathy and rhabdomyolysis. It is necessary to control the concentration of creatinine kinase.In the case of a significant increase in the concentration of creatinine kinase or if it is diagnosed, or there is a suspicion of the development of myopathy or rhabdomyolysis, therapy with HMG-CoA reductase inhibitors should be discontinued.

Ibrutinib: Moderate inhibitors of the CYP3A4 isoenzyme, such as fluconazole, increase plasma concentrations of ibrutinib and may increase the risk of toxicity.

If the use of drugs in combination cannot be avoided, it is necessary to reduce the dose of ibrutinib, as indicated in the instructions for medical use of ibrutinib, and ensure careful clinical observation.

Losartan: fluconazole inhibits the metabolism of losartan to its active metabolite

(E-3174), which is responsible for most of the effects associated with angiotensin II receptor antagonism. Regular monitoring of blood pressure is required. Methadone: Fluconazole can increase the plasma methadone concentration.

Methadone dose adjustment may be necessary.

Non-steroidal anti-inflammatory drugs (NSAIDs): Cmax and AUC of flurbiprofen increase by 23% and 81%, respectively.Similarly, the Cmax and AUC of the pharmacologically active isomer [S – (+) – ibuprofen] increased by 15% and 82%, respectively, with the simultaneous use of fluconazole with racemic ibuprofen (400 mg).

With the simultaneous use of fluconazole at a dose of 200 mg per day and celecoxib at a dose of 200 mg, Cmax and AUC of celecoxib increase by 68% and 134%, respectively. In this combination, it is possible to reduce the dose of celecoxib by half.

Despite the lack of targeted studies, fluconazole may increase the systemic exposure of other NSAIDs metabolized by the CYP2C9 isoenzyme (eg, naproxen, lornoxicam, meloxicam, diclofenac).Dose adjustment of NSAIDs may be necessary.

With the simultaneous use of NSAIDs and fluconazole, patients should be under close medical supervision in order to identify and control adverse events and toxicity associated with NSAIDs.

Olaparib: Moderate inhibitors of the CYP3A4 isoenzyme, such as fluconazole, increase the plasma concentration of olaparib. Their simultaneous use is not recommended. If it is impossible to avoid simultaneous use, it is necessary to reduce the dose of olaparib to 200 mg 2 times a day.

Oral contraceptives: with the simultaneous use of a combined oral contraceptive with fluconazole at a dose of 50 mg, a significant effect on the level of hormones has not been established, while with a daily intake of 200 mg of fluconazole, the AUC of ethinyl estradiol and levonorgestrel increase by 40% and 24%, respectively, and with taking 300 mg of fluconazole once a week, the AUC of ethinylestradiol and norethindrone increase by 24% and 13%, respectively. Thus, repeated use of fluconazole at the indicated doses is unlikely to affect the effectiveness of the combined oral contraceptive.

Phenytoin: Concomitant use of fluconazole and phenytoin may be accompanied by a clinically significant increase in phenytoin concentration. If it is necessary to simultaneously use both drugs, the concentration of phenytoin should be monitored and its dose adjusted accordingly in order to ensure a therapeutic concentration in the blood serum.

Ivacaftor: when used simultaneously with ivacaftor, a stimulant of the cystic fibrosis transmembrane conductance regulator (CFTR), an increase in the exposure of ivacaftor was observed by 3 times and the exposure of hydroxymethyl ivacaftor (M1) by 1.9 times.For patients concomitantly taking moderate inhibitors of the isoenzyme CYP3A, such as fluconazole and erythromycin, it is recommended to reduce the dose of ivacaftor to 150 mg once a day.

Prednisone: there is a report on the development of acute adrenal cortex insufficiency in a patient after liver transplantation against the background of discontinuation of fluconazole after a three-month course of therapy. Presumably, discontinuation of fluconazole therapy caused an increase in the activity of the isoenzyme CYP3A4, which led to an increased metabolism of prednisone.

Patients receiving combination therapy with prednisone and fluconazole should be under close medical supervision when discontinuing fluconazole in order to assess the state of the adrenal cortex.

Rifabutin: Concomitant use of fluconazole and rifabutin may increase serum concentrations of the latter by up to 80%. With the simultaneous use of fluconazole and rifabutin, cases of uveitis have been described. Patients receiving concomitant rifabutin and fluconazole should be closely monitored.

Saquinavir: AUC increases by approximately 50%, Cmax – by 55%, clearance of saquinavir decreases by approximately 50% due to inhibition of hepatic metabolism of the CYP3A4 isoenzyme and inhibition of P-glycoprotein. Dose adjustment of saquinavir may be necessary.

Sirolimus: an increase in the concentration of sirolimus in blood plasma, presumably due to inhibition of the metabolism of sirolimus through inhibition of the CYP3A4 isoenzyme and P-glycoprotein.This combination can be used with appropriate dose adjustment of sirolimus depending on effect / concentration.

Sulfonylurea preparations: fluconazole, when taken simultaneously, leads to an increase in the half-life of oral sulfonylureas (chlorpropamide, glibenclamide, glipizide and tolbutamide). Patients with diabetes mellitus can be prescribed the combined use of fluconazole and oral sulfonylureas, but the possibility of hypoglycemia should be taken into account, in addition, regular monitoring of blood glucose and, if necessary, dose adjustment of sulfonylureas are required.

Tacrolimus: the simultaneous use of fluconazole and tacrolimus (by mouth) leads to an increase in serum concentrations of the latter by 5 times due to inhibition of the metabolism of tacrolimus, which occurs in the intestine through the isoenzyme CYP3A4. No significant changes in the pharmacokinetics of the drugs were observed with intravenous tacrolimus. Cases of nephrotoxicity have been reported. Patients taking oral tacrolimus and fluconazole at the same time should be closely monitored.The dose of tacrolimus should be adjusted depending on the degree of increase in its concentration in the blood.

Theophylline: when used simultaneously with fluconazole at a dose of 200 mg for

14 days, the average rate of plasma clearance of theophylline decreases by 18%. When prescribing fluconazole to patients taking high doses of theophylline, or to patients at increased risk of developing toxic effects of theophylline, the symptoms of theophylline overdose should be monitored and, if necessary, the therapy should be adjusted accordingly.

Tofacitinib: the exposure of tofacitinib is increased when it is used together with drugs that are simultaneously moderate inhibitors of CYP3A4 and CYP2C19 isoenzymes (for example, fluconazole). Dose adjustment of tofacitinib may be necessary.

Tolvaptan: the exposure of tolvaptan is significantly increased (AUC by 200%, Cmax by 80%) with the combined use of tolvaptan, a substrate CYP3A4, and fluconazole, a moderate inhibitor of CYP3A4.At the same time, there is a risk of a significant increase in the incidence of adverse events, in particular, such as increased urine output, dehydration and acute renal failure. With the simultaneous use of these drugs, you should reduce the dose of tolvaptan and carefully monitor the patient’s condition.

Vinca alkaloid: Despite the lack of targeted studies, it is suggested that fluconazole may increase plasma concentrations of vinca alkaloids (e.g. vincristine and vinblastine) and thus lead to neurotoxicity, which may be related to depression isoenzyme CYP3A4.

Vitamin A: there is a report of one case of development of adverse reactions from the central nervous system (CNS) in the form of pseudotumor of the brain with the simultaneous use of all-trans-retinoic acid and fluconazole, which disappeared after discontinuation of fluconazole. The use of this combination is possible, but one should remember about the possibility of adverse reactions from the central nervous system.

Zidovudine: with simultaneous use with fluconazole, there is an increase in Cmax and AUC of zidovudine by 84% and 74%, respectively.This effect is probably due to a decrease in the metabolism of the latter to its main metabolite. Before and after therapy with fluconazole at a dose of 200 mg per day for 15 days, patients with AIDS and ARC (AIDS-related complex) found a significant increase in the AUC of zidovudine (20%).

Patients receiving this combination should be monitored for side effects of zidovudine.

Voriconazole (inhibitor of isoenzymes CYP2C9, CYP2C19 and CYP3A4): simultaneous use of voriconazole (400 mg 2 times a day on the first day, then 200 mg 2 times a day for 2.5 days) and fluconazole (400 mg on the first day, then 200 mg per day for 4 days) in 8 healthy male subjects led to an increase in Cmax and AUC of voriconazole by 57% and 79%, respectively.It has been shown that this effect persists with decreasing the dose and / or decreasing the frequency of administration of any of the drugs. Concomitant use of voriconazole and fluconazole is not recommended.

Studies of the interaction of oral forms of fluconazole when taken simultaneously with food, cimetidine, antacids, as well as after total body irradiation to prepare for bone marrow transplantation have shown that these factors do not have a clinically significant effect on the absorption of fluconazole.

The listed interactions were established with repeated use of fluconazole; drug interactions resulting from a single dose of fluconazole are not known.

Physicians should take into account that interaction with other drugs has not been specifically studied, but it is possible.

Treatment and prevention of candidiasis (thrush)

The first symptom of thrush (candidiasis) is a sharp, rapidly growing and almost constant itching in the perineum and vagina.Due to the large number of nerve endings in this part of the body, the manifestations of vaginal candidiasis are especially painful for a woman.

Unlike venereal diseases, thrush is caused not by infectious bacteria or parasitic microorganisms, but by yeast-like fungi that inhabit our body from the very moment of birth. Getting on the skin of a newborn at the time of its passage through the birth canal of the mother, fungi soon spread throughout the body: they live on the skin and nails, mucous membranes of the oral cavity, intestines, respiratory and birth canals, and even in the internal organs of a healthy person.

In normal times, Candida fungi are distinguished by their peaceful nature. But if we just overcool, weaken as a result of illness, stress, overwork, abuse antibiotics or hormonal drugs – peaceful neighbors get out of the control of the immune system and turn into arrogant aggressors. At a high rate, fungi begin to multiply and become dangerous. In newborns and seriously ill patients, as a rule, candidiasis of the oral mucosa develops. In women, whose hands are many and often in the water, candidiasis of the nail folds is usually found.In children and overweight people, Candida fungi can inhabit folds of skin in the groin, under the breast and between the toes. And most women are notorious for the vaginal form of candidiasis.

The first manifestation of thrush is a burning sensation in the vaginal area, its swelling and excruciating itching, forcing a woman to scratch the areas affected by the fungus, which causes even more irritation. Then a white bloom appears on the vaginal mucosa, as well as a grayish discharge of a curdled consistency. However, you may simply not notice the discharge, because severe itching calls for increased hygiene measures.A gynecologist will be able to assess the overall picture, so you should not make a diagnosis only on the basis of already familiar sensations, but you should definitely go to the doctor.

Asexual yeast infection is not the only way to get sick. Fungi can also enter the vagina during unprotected intercourse.

And, by the way, often along with them you can catch Trichomonas and bacteria, which are already causing more serious diseases of the genital area. Your unfaithful constant partner – a neutral carrier of the disease between two women can also “give” you thrush.

However, physical suffering is not the only cause for concern. Candidiasis is sometimes the first sign of serious problems of the whole body – from a general decrease in immunity to ovarian dysfunction. Therefore, thrush should be treated carefully and do not postpone a visit to the gynecologist. How to alleviate your lot?

If thrush has appeared only once, local treatment is sufficient. Your doctor will decide which vaginal suppository is best for you. There are many drugs today, so this problem can be solved.

In the process of treating thrush, doctors urge the cessation of sexual activity for ten days. After all, harmful fungi can temporarily emigrate to your partner, where, without causing him problems, they will wait out the course of your treatment, and then they will again declare themselves. That is why it is advisable to diagnose and treat sexually transmitted diseases in both partners at the same time.

Helpful Hints

  • In the course of treatment, it is worth excluding from the diet spicy, spicy and pickled foods that make the urine too caustic, which can further provoke itching.It is better to lean on fresh vegetables, fruits, dairy products, cereals.
  • Avoid for a while from prolonged physical activity, heavy meals, prolonged exposure to heat, wearing tight-fitting clothing or a wet swimsuit – from anything that leads to profuse sweating, diaper rash and skin irritation.
  • Change your pads frequently during your period. Menstrual flow is a good breeding ground for pathogenic bacteria, and the immune system is weakened these days.It is better not to use tampons during this period.
  • Constantly recurrent thrush can sometimes indicate the presence of a more serious genital infection. In this case, smear analysis and consultation of a qualified specialist are required.

Diaper rash under breasts – causes, symptoms, diagnosis and treatment

Diaper rash under the breast is an infectious and inflammatory skin disease that occurs in the submammary folds due to high humidity and infection.Violation of personal hygiene and excessive sweating predisposes to diaper rash. It manifests itself in the form of redness, which is limited to areas of contact skin, maceration with an unpleasant odor, whitish or purulent bloom. Diagnostics is carried out on the basis of clinical data, supplemented by microbiological research. For treatment, local agents with antiseptic, drying, antibacterial effects are used.

General

Diaper rash, or intertriginous dermatitis, is more commonly diagnosed in women.Rarely, the disease appears in men with gynecomastia and obesity, as well as concomitant diabetes mellitus. The incidence of diaper rash in the folds of the mammary glands among females increases with age. This is due to characteristic changes in skin function, a decrease in immunity and an increase in breast volume. Many women refuse to use a bra with age, which, with a large breast, increases the risk of developing diaper rash.

Diaper rash under the breast

Causes

The development of diaper rash under the breast requires a combination of several factors.Under normal conditions, sweat is bactericidal and inhibits the growth of microorganisms. But with a combination of sweating, some systemic diseases or special conditions against the background of friction of the skin under the breast, diaper rash occurs. The main causes of pathology are:

  • Hyperhidrosis . With increased sweating and lack of ventilation of the skin, uric acid, urea, chlorides remain on the surface of the skin, causing damage and maceration. In lactating women, the temperature of the mammary glands rises, so sweating increases in the folds under them.
  • Personal hygiene violations . Refusal to wear a large breast bra leads to mastoptosis, the skin inside the fold is in close contact, does not allow sweat to evaporate. If a woman ignores water procedures, especially in the heat, sweat becomes a breeding ground for bacteria.
  • Endocrine pathologies . Sweating and the risk of diaper rash increase with hyperthyroidism, and in patients with diabetes mellitus, Itsenko-Cushing’s syndrome, pathology is often combined with a fungal or microbial infection.Skin candidiasis in diabetes can develop not only under the breast, but also in any skin folds.
  • Decreased immunity . With age, there is a natural decrease in immune defense, a change in the composition of sweat. Its reaction can change from acidic to neutral. Therefore, older women with macromastia are more likely to develop intertriginous dermatitis.
  • Pregnancy . In pregnant women, the enlarged belly and mammary glands form an area of ​​close contact.In this case, a cotton bra can protect against skin thorns. If not worn, diaper rash may appear under the breasts. The risk also increases from a natural decrease in immunity in pregnant women.

Pathogenesis

Sweat glands produce sweat continuously. On average, up to 800 ml of it are released per day, and with increased sweating, much more. In the folds of the dermis, it does not evaporate, but mixes with the secretion of the sebaceous glands and becomes a breeding ground for bacteria.Constant moisture, friction during movement creates areas of maceration. The skin becomes inflamed, swelling and redness occurs.

With the active multiplication of bacteria, the damage increases. Small vesicles with purulent contents appear in the dermis. Candida infection may join. The fungus affects the upper layer of the dermis, forms colonies, which macroscopically look like a white bloom. When it is removed with a spatula or cotton swab, a smooth layer of skin is exposed, which bleeds easily.

Upon successful treatment, the surface of the skin begins to dry out and may begin to peel off. Healing occurs without the formation of a rough scar, diaper rash does not damage the basal layer of the skin. But with the preservation of risk factors, uncontrolled diabetes, immunodeficiency, the likelihood of recurrence of diaper rash is high. It can also be combined with a similar process in the armpits, groin, between the buttocks.

Classification

Diaper rash in the folds of the breast can be associated with nonspecific microbial infection or candidiasis.Rarely, dermatitis is caused by other types of fungus or allergies. In clinical practice, a classification is used depending on the type of pathogen. This allows you to navigate the treatment methods. The course of the disease is classified as follows:

  • 1 stage . The skin turns red, looks edematous, but their integrity is not compromised.
  • 2 stage . The upper layer of the skin is damaged, cracks, bubbles, ulcers appear on it.
  • 3 stage . Severe inflammation with the addition of a fungal infection or bacterial infection.

Symptoms of diaper rash under the breast

Before the development of a vivid clinical picture, the woman feels discomfort under the breast, itching appears, which may periodically intensify. Then the skin turns red, looks edematous. A burning sensation joins the itching under the breast. A woman combs the site of inflammation, injures it, which further aggravates the symptoms.At first, hygiene procedures alleviate the condition, but after taking a shower, skin tightness is felt, the itching may intensify.

Pustular eruptions appear on the skin of the breast. Their contents can be pus or exudate. They spontaneously open up, the diaper rash becomes weeping. Exudation continues through the inflamed tissue surface. Liquid discharge increases the discomfort, and the affected area can gradually invade healthy skin. The general condition at this stage does not suffer, but an unpleasant odor appears.

Attachment of infection can occur at any stage. Opportunistic bacteria get from healthy skin during scratching of the lesions. They multiply actively, form purulent foci. With candidiasis, persistent itching is noted, white films, grains are visible on the skin, which are easily separated with a spatula. At the same time, the skin begins to bleed. Peeling may appear along the edges of the diaper rash.

Complications

Diaper rash in the skin folds of the mammary gland rarely occurs with complications.Sometimes, with untimely treatment, a bacterial infection can penetrate into the deep layers of tissues. In advanced cases, this leads to the formation of phlegmon. Its development is accompanied by an increase in temperature, the addition of symptoms of intoxication, a general deterioration in the condition. Cellulitis requires surgical treatment. If a woman’s trigger factors persist, then diaper rash becomes chronic, under the influence of treatment, her symptoms may decrease, and later recur.

Diagnostics

When examining women with diaper rash of the skin of the mammary glands, it is necessary to carefully collect anamnesis, take into account age, social status.Diagnostics is carried out by a dermatologist, with diagnosed diabetes, hyperthyroidism or other hormonal diseases, an endocrinologist’s consultation is necessary. The following methods are used for diagnostics:

  • Bacterioscopic . A smear is taken from the focus to determine the type of pathogens. The results reveal coccal flora, desquamated epithelial cells, leukocytes, with a fungal infection – hyphae and yeast cells.
  • Cultural. Used when therapy is ineffective to clarify the composition of the microflora and determine the sensitivity to antibiotics. With the fungal form of diaper rash, the method allows you to differentiate candida and actinomycetes and to identify which antimycotics are effective.
  • Hematological examinations . A blood test for glucose, glucose tolerance test is necessary for patients with diabetes mellitus or if it is suspected. According to the indications, a study of thyroid hormones, adrenal glands is carried out.

Treatment of diaper rash under the breast

In the acute period, a sparing diet is prescribed, excluding irritating foods, spicy, salty, sweet, as well as foods that can cause allergies. A woman should wear a cotton bra that is not underwired, which traumatizes the skin and increases friction. Careful observance of hygiene is necessary, they take a shower 2 times a day using baby soap. Air baths are carried out periodically.

Conservative therapy

Treatment is carried out at home, in severe cases, hospitalization is required at a dermatovenerologic dispensary.Most drugs are used topically. Systemic therapy is carried out for protracted infectious processes. Physiotherapy is prescribed as an adjunct method to complement drug therapy. The courses are carried out by UFO of the affected area. The following types of preparations are used:

  • Antiseptic solutions . They help to disinfect the skin and suppress the activity of bacteria. Chlorhexidine, miramistin, furacillin are used. Decoctions of a string, chamomile, calendula have an antiseptic and anti-inflammatory effect.
  • Desiccants . Allow to reduce exudation, reduce the activity of sweat glands, stop the progression of inflammation. Apply drugs with copper sulfate, zinc paste, resorcinol solution. Teymurov’s ointment based on boric and salicylic acid, zinc, talc and other substances is effective; Lassar paste can be used.
  • Reparative means . Dexpanthenol drugs help to speed up the restoration of the skin, soften the dermis at the site of diaper rash.It nourishes the skin, penetrates the cells, where it turns into pantothenic acid and accelerates cell division.
  • Hormonal ointments . Glucocorticoids have a pronounced antipruritic and anti-inflammatory effect, after application, redness and swelling decrease, and discomfort under the mammary gland disappears. But long-term use leads to the development of candidiasis.
  • Antibacterials . Antibiotic ointments and creams are used prophylactically in women at risk of infection or to treat inflammation with confirmed bacterial contamination.Use a solution of aluminum acetate, streptocide powder, liniment lincomycin.
  • Antifungal agents . Appointed after confirmation of candidiasis in the breast fold. Effective drugs based on pimafucin, nystatin, clotrimazole, miconazole. They help suppress the growth and reproduction of fungi, reduce itching, relieve burning.

Surgical treatment

Operative treatment is required for a widespread infectious process that does not respond to antibiotic treatment and is constantly progressing.If the inflammation has spread to the subcutaneous fat, phlegmon has formed, it is opened by surgery. For treatment, the woman is hospitalized in the surgical department. After the intervention on the chest, conservative therapy is prescribed.

Forecast and prevention

With timely treatment started and following the doctor’s recommendations, the prognosis for diaper rash of the skin under the breast is favorable. The main preventive measure is compliance with hygiene standards. Women need to take a shower every day, wear underwear made from natural fabrics, and use antiperspirants if they tend to sweat.Places of diaper rash should not be powdered with starch-based products so as not to provoke a fungal infection. You also need to treat concomitant diseases, with diabetes, follow a diet and choose the right main treatment.

IVF Clinic | Oh, this thrush!

Candidiasis or thrush is sometimes the first sign of serious problems of the whole body – from a general decrease in immunity to ovarian dysfunction.Therefore, thrush should be treated carefully and do not postpone a visit to the gynecologist. Why is thrush so terrible?

See also: “Vaginal candidiasis: treatment and prevention”

The first symptom of thrush (candidiasis) is a sharp, rapidly growing and becoming almost constant itching in the perineum and vagina. Due to the large number of nerve endings in this part of the body, the manifestations of vaginal candidiasis are especially painful for a woman.

Unlike venereal diseases, thrush is caused not by infectious bacteria or parasitic microorganisms, but by yeast-like fungi that live in our body from the moment of birth.Getting on the skin of a newborn at the time of its passage through the birth canal of the mother, fungi soon spread throughout the body: they live on the skin and nails, mucous membranes of the oral cavity, intestines, respiratory and birth canals, and even in the internal organs of a healthy person.

In normal times, Candida fungi are distinguished by their peaceful nature. But if we just overcool, weaken as a result of illness, stress, overwork, abuse antibiotics or hormonal drugs – peaceful neighbors get out of the control of the immune system and turn into arrogant aggressors.At a high speed, fungi begin to multiply and become dangerous. In newborns and seriously ill patients, as a rule, candidiasis of the oral mucosa develops. In women, whose hands are many and often in the water, candidiasis of the nail folds is usually found. In children and overweight people, Candida fungi can inhabit folds of skin in the groin, under the breast and between the toes. And most women are notorious for the vaginal form of candidiasis.

The first manifestation of thrush is a burning sensation in the vaginal area, its swelling and excruciating itching, forcing a woman to scratch the areas affected by the fungus, which causes even more irritation.Then a white bloom appears on the vaginal mucosa, as well as a grayish discharge of a curdled consistency. However, you may simply not notice the discharge, because severe itching calls for increased hygiene measures. A gynecologist will be able to assess the overall picture, so you should not make a diagnosis only on the basis of already familiar sensations, but you must definitely go to the doctor.

Asexual yeast infection is not the only way to get sick. Fungi can also enter the vagina during unprotected intercourse.

And, by the way, often along with them you can catch Trichomonas and bacteria, which are already causing more serious diseases of the genital area. Your unfaithful constant partner – a neutral carrier of the disease between two women can also “give” you thrush.

However, physical suffering is not the only cause for concern. Candidiasis is sometimes the first sign of serious problems of the whole body – from a general decrease in immunity to ovarian dysfunction. Therefore, thrush should be treated carefully and do not postpone a visit to the gynecologist.

How to ease your lot?

If thrush has appeared only once, local treatment is sufficient. Your doctor will decide which vaginal suppository is best for you. There are many drugs today, so this problem can be solved.

In the process of treating thrush, doctors urge the cessation of sexual activity for ten days. After all, harmful fungi can temporarily emigrate to your partner, where, without causing him problems, they will wait out the course of your treatment, and then they will again declare themselves.That is why it is advisable to diagnose and treat sexually transmitted diseases in both partners at the same time.

USEFUL TIPS

In the course of treatment, it is worth excluding from the diet spicy, spicy and pickled foods that make the urine too caustic, which can further provoke itching.