Nipple pain without visible damage

Nipple pain is caused by inflammation

The symptoms and signs of nipple pain (without visible nipple wounds or cracks) are consistent with inflammation, which results from excessively high stretching or deformational mechanical loads applied during suckling or mechanical milk removal.

Inflammation, and its associated nociceptive and possibly also neuropathic pain, continues between feeds.

How do women describe nipple pain?

Women describe symptoms of nipple and breast pain and discomfort along a spectrum of intensity with highly variable descriptors,1 including terms such as

• Cutting

• Throbbing

• Pinching

• Burning

• Radiating

• Stabbing.

A woman's description of her pain does not help with the diagnosis. Her pain may occur predominantly during feeds, after feeds, or between feeds - or at a mix of these times.

What signs might accompany nipple pain in the absence of visible wounds of the nipple skin?

Two common signs of nipple-areolar complex skin and nipple stromal inflammation are

• Erythema

• Swelling.

Sometimes, the inflamed nipple epithelium appears pink and shiny when it is being subjected to repetitive microtrauma.

What causes fine white scale on the nipple?

A fine white scale (or 'peeling') may result from a hyperkeratotic response of the stratum corneum, which occurs in the context of repetitive micro-trauma or moisture-associated skin damage.

Itchiness is hypothesised to result from histamine release, which stimulates nerve cells during the proliferative phase of wound healing.2 You can find out about the processes of wound healing here.

The symptoms of burning, radiating, stabbing, or itching pain, which occur between breastfeeds, and which may be associated with signs of a shiny pink nipple and fine white skin flakes, are not indicative of mammary candidiasis.3 You can find out more here.

Nipple pain with visible wounds

Over half of women with nipple pain also develop nipple wounds

Over half of women with nipple pain develop visible wounds. These visible signs of damage are associated with increased pain.39 In 2019 Coca et al used the Numeric Rating Scale of 0-10, to show that women with nipple damage reported a mean score of 6.2 in the first week and 5.8 after that period. This compares to women without visible damage who reported a mean of 2.7.

In addition to erythema and swelling, the visible signs of nipple damage are

• Blisters

• Bruises (or purpura)

• Cracks or fissures

• Ulcers and exudate

• Scabbing.

The woman in the image above is experiencing nipple pain. Close examination of this photo shows a re-epithelising crack at 11 o'clock on the face of her nipple, and also possibly a small healing ulcer or area of purpura in the centre of her nipple face, although F2F clinical examination of the nipple would be required to be sure of that. What matters clinically though, is this woman's experience of pain, and the need to offer her an intervention that eliminates nipple and breast tissue drag when her baby breastfeeds.

References

1. Nakamura M, Asake Y. An evaluation of the signs of nipple trauma associated with breastfeeding: a Delphi study. Journal of Human Lactation. 2022;38(3):548-558.

2. Coca KP, Amir LH, Da Silva Alves MdR, Barbieri M, Marcacine KO, De Vilhena Abrao ACF. Measurement tools and intensity of nipple pain among women with or without damaged nipples: a quantitative systematic review. Journal of Advanced Nursing. 2019;75:1162-1172.

3. McClellan HL, Hepworth AR, Garbin CP, Rowan MK, Deacon J, Hartmann PE, et al. Nipple pain during breastfeeding with or without visible trauma. Journal of Human Lactation. 2012;28(4):511-521.

4. Rodrigues M, Kosaric N, Bonham CA, Gurtner GC. Wound healing: a cellular perspective. Physiological Reviews. 2019;99(1):665-706.

5. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health. 2021;17:17455065211031480.