APNO / All Purpose Nipple Ointment (mupirocin, betamethasone, miconazole)

Section 1.1

Midwives may independently prescribe, order and administer this drug.

All Purpose Nipple Ointment (APNO) or Jack Newman’s Nipple Cream®. The antibiotic murpirocin combats or prevents bacterial infections, including staphylococcus; the corticosteroid betamethasone reduces inflammation and the pain associated with inflammation; and the antifungal miconazole combats or prevents monilial infections and relieves associated pruritis.

The corticosteroid is absorbed through normal intact skin, with percutaneous absorption increased in the presence of skin irritation or inflammation. The antibacterial and antifungal agents are absorbed where the skin is inflamed.

Indications and Clinical Use:

Used as a topical treatment for irritation of the nipple, with or without secondary bacterial infection.

Contraindications:

It should not be used on viral or tubercular lesions, or by anyone with a systemic viral infection or a history of allergy to any of the ingredients.

Warnings and Precautions:

If burning, itching, or local irritation increases with use, treatment should be discontinued. While generally well tolerated, APNO should not be used over large areas of the skin, and is not intended for prolonged use.

If the condition has not improved within a week, physician consultation is indicated.

Pregnancy:

Category C
Topical use to small area is not associated with problems

Lactation:

Topical use of these ingredients is not associated with problems

Dosage and Administration:

This cream is compounded by a pharmacist using 15 grams mupirocin ointment (Bactroban® 2%), and 15 grams betamethasone ointment (0.1%) to which is added miconazole powder to a final concentration of 2% (clotrimazole powder may be substituted for miconazole, if miconazole is unavailable). Antifungal cream may be used if powder is unavailable. Ibuprofen powder may be added to a final concentration of 2% to manage pain. Changes to the formula may be made from time to time as new evidence emerges.

The cream should be applied sparingly to the nipples after each breastfeed and not washed or wiped off, even prior to the next feed. If Gentian violet is being used, the cream should not be applied at the same time.

Onset of Action:

Only a small amount of topically applied mupirocin is absorbed into the systemic circulation where it is rapidly metabolized.