All Purpose Nipple Ointment (APNO)
call our nipple ointment “all purpose” since it contains ingredients
that help deal with multiple causes or aggravating factors of sore
nipples. “Good medicine” calls for the single “right” treatment for the
“right” problem, true enough, but mothers with sore nipples don’t have
time to try out different treatments that may or may not work, so we
have combined various treatments in one ointment. Of course, preventing
sore nipples in the first place would be the best treatment and often
adjusting how the baby takes the breast can do more than anything to
decrease and eliminate the mother’s nipple soreness (See information
sheets When Latching, Sore Nipples as well as the video clips at the website nbci.ca.
The APNO contains:
By using a powder, the
concentration of the other two ingredients is not as decreased as they
would be if another ointment were used for the anti-fungal agent (for
example, nystatin ointment). Thus, in the above preparation the
concentration of the betamethasone become 0.05% (due to combination with
the mupirocin) and the mupirocin concentration is decreased to 1%.
Note that nystatin ointment, which we used to use and which decreases
the concentration of the other ingredients, is far inferior to
miconazole and also tastes bad.
Mupirocin 2% ointment. Mupirocin (Bactroban is the trade name)
is an antibiotic that is effective against many bacteria, particularly
Staphylococcus aureus including MRSA (methicillin resistant Staphylococcus aureus).
Staphylococcus aureus is commonly found growing in abrasions or cracks
in the nipples and probably makes worse whatever the initial cause of
sore nipples is. Interestingly, mupirocin apparently has some effect
against Candida albicans (commonly, but inaccurately called
“thrush” or “yeast”). Treatment of sore nipples with an antibiotic
alone sometimes seems to work, but we feel that the antibiotic works
best in combination with the other ingredients discussed below.
Although mupirocin is absorbed when taken by mouth, it is so quickly
metabolized in the body that it is destroyed before blood levels can be
measured. Moreover most of it gets stuck to the skin so that very
little is taken in by the baby. Thus it is safe for the baby to swallow
if indeed he gets any.
Betamethasone 0.1% ointment. Betamethasone is a corticosteroid,
which like all corticosteroids, decreases inflammation. A large part of
the pain mothers experience when they have sore nipples is due to
inflammation. The redness of the nipples and areolas is another sign of
inflammation. By decreasing the inflammation, the APNO also decreases
the pain the mother feels. Most of the betamethasone in the ointment is
absorbed into the skin by the mother, so that the baby takes in very
Miconazole powder to a final concentration of 2%. Miconazole is
an antifungal agent. It is very effective against Candida albicans. We
feel the concentration of 2% miconazole is a good one, but because the
pharmacist adds a powder to the above two ingredients, s/he can change
the concentration of miconazole so that it can be increased to 3% or
even 4% or decreased to less than 2%. We feel 2% is the best
concentration for most situations. Fluconazole powder to 2% may be
substituted for miconazole and so can clotrimazole powder to 2%, but we
believe that clotrimazole (Canesten) irritates more than the other drugs
in the same family. Miconazole cream or gel cannot be substituted for
miconazole powder as the compound will usually separate. If you live in
a place where miconazole or any of the above mentioned drugs
(fluconazole, clotrimazole) are not easily available as powders to be
mixed into the APNO, it is probably better to use only the mupirocin and
betamethasone ointments mixed together than add a cream or gel or
nystatin ointment for example.
I write the prescription this way.
Total: about 30 grams combined
Mupirocin ointment 2%: 15 grams
Betamethasone ointment 0.1%: 15 grams
To which is added miconazole powder to a concentration of 2% miconazole
Apply sparingly after each feeding. Do not wash or wipe off
If possible, try to get the prescription filled at a compounding
pharmacy. At least they will not tell you there is no such thing as
miconazole powder. You can find a list of compounding pharmacies in
Canada and the US and maybe some other countries by going to the website
iacprx.org. Click “For Patients, Pet Owners” in the red box on the
left side of the page, then click “Finding a Compounding Pharmacist Near
You”. You will need to sign in and then you can find your nearest
compounding pharmacy. Canadians: make sure that you leave a space
between the two sets of 3 letters in the postal code: M2K 2E1, not
How do I use the ointment?
How long can I use the ointment?
Apply it sparingly after each feeding. “Sparingly” means that you apply
just enough to make the nipples and areola glossy or shiny.
Do not wash it off or wipe it off, even if the baby comes back to the breast earlier than expected.
Somehow the “word” has gotten around to use the ointment for only two
weeks. This is unfortunate since many mothers are getting so much
better, but not pain free, by the time they believe they have to stop
the ointment. Apparently pharmacists have said that the steroid in the
ointment will cause “thinning” of the skin. This is a concern with any
steroid one puts on the skin, but in our experience this has not
occurred with our ointment and many mothers have used it for months.
However, any drug should be used for the shortest period of time
necessary, whether it’s taken by mouth or put on the skin or any other
way it’s being given. The same is true for our ointment. There is no
problem using the ointment for 2 or 3 or even more weeks, but if you
still need the ointment after two or three weeks, or you pain returns
after you have stopped it, you should get “hands on” help again to find
out why and fix the way the baby is taking the breast, for example.
Indeed, the most important feature of decreasing nipple pain is getting
the “best latch possible”. Many teach a method of latching on that is
different from what we teach. Naturally, based on our experience and
from feedback, we think we have an effective and successful method. See
the information sheet When Latching, and watch the video clips at the website and nbci.ca.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
All purpose nipple ointment, 2009©