Introduction

Nipple fissures are cracks in the nipple that are painful and can affect either one or both breasts. They can arise in any individual regardless of sex. Nipple fissures commonly affect those who are breastfeeding, birth parents and athletes. Around 80% - 90% of birth parents and breastfeeding birth parents experience nipple fissures and pain, usually during the second to third week following delivery.¹

It is essential to understand the cause of nipple fissures so that proper prevention and treatment can be implemented. Untreated nipple fissures can result in bleeding and infections like lactational mastitis.¹

Breastfeeding-related causes

Breastfeeding is the most common cause of nipple fissures due to several different reasons. 

Poor latch or positioning

This occurs when the baby is not positioned appropriately and is poorly attached to the breast. The baby should be attached so the nipple rests against the soft palate at the back of their mouth. The baby’s full mouth should be over the nipple and most of the areola. When the nipple is closer to the front of the baby’s mouth, it will likely be pinched against the hard palate. Also, it should not be necessary to reposition during feeding, and the baby should not be required to turn its head to find the nipple.^1,2 

A condition called tongue tie can cause a baby to not latch and use their tongue correctly. Notably, white, flattened or wedged nipples at the end of a feed are an indication that the baby may not be positioned and latching properly, as well as the baby appearing disturbed between feeds.²

Frequent or prolonged feeding

It is possible that extended feeding, especially with a less than favourable position and attachment, can lead to nipple damage. The pressure of the baby’s suckling can lead to blanching, where the nipple’s blood vessels are constricted and compression of the nipple. Dryness and cracking can then occur.^1,3

Use of breast pumps

Nipple fissures and pain can arise from using breast pumps in the wrong flange (breast shield) size, as well as high suction settings.¹

Engorgement or mastitis

Due to the breasts becoming overly filled with milk (engorgement), it is possible that excess fluid can lead to the nipple tissue stretching and eventually cracking. Mastitis is when the breast is swollen, hot and painful and is quite common in breastfeeding birth parents, although it also affects other people. Swelling can make it difficult for the baby to latch properly and increase strain and tension on the nipple.^1,4

Friction-related causes

Nipple fissures can occur as a result of abrasion or rubbing of the nipples against material.

Tight or rough clothing

The friction created when the wet, sweaty skin makes contact with clothing, especially ill-fitting ones or those made of rough, synthetic fabrics, can cause nipple cracks when exercising.¹

Physical activity

It is common for athletes, mainly joggers, runners, cyclists and surfers to get nipple fissures. Jogger’s nipple is a term used to describe nipple fissures, especially in long-distance runners. Surfers are usually affected due to their exposed nipples grazing their surfboards repeatedly.¹ 

Improper nursing pads 

Using inappropriate breast pads, like those with plastic backing, can lead to nipple fissures.²

Skin conditions

Skin-related issues are another potential reason for nipple damage and fissures.

Eczema or dermatitis

Eczema may be due to an overreaction of the immune system to chemicals in products like soaps and creams or irritants in the environment, genetics, or emotional triggers. This condition causes the skin to be dry, inflamed, and itchy and presents with a rash. Nipple fissures can then occur when eczema the nipples become dry and cracked.^1,5

Psoriasis

Similar to dermatitis, psoriasis can happen because of a dysfunctional immune system, genetics or triggers like skin injury, smoking, stress, etc. In psoriasis, the skin has dry and scaly patches.^3,6

Infections

Bacterial, fungal and viral infections can cause nipple discharge, rash, crusting and fissuring.^1,3

FAQs

What is Paget's disease of the breast?

Paget’s disease of the breast is a rare type of breast cancer that typically affects the skin of the nipple and the darker area surrounding it (areola), which mainly affects persons after age 50. The symptoms are similar to eczema, such as redness, flaking, itching, or crusting of the nipple skin. However, unlike typical skin conditions, Paget’s disease is usually associated with an underlying breast cancer, either ductal carcinoma in situ (DCIS) or invasive breast cancer.⁷

What is nipple dermatitis while breastfeeding?

Nipple dermatitis while breastfeeding refers to inflammation and irritation of the nipple skin, often triggered or worsened by frequent feeding. It can be caused by an underlying skin condition like eczema, contact irritation from detergents or nipple creams, or an allergic reaction to breast pads or topical products. The skin becomes red, itchy, flaky, and sometimes painful.⁸

What causes nipple friction?

Nipple friction is commonly caused by repetitive rubbing of the nipple against clothing or sports gear, especially during physical activities like running, cycling, or vigorous workouts. Tight, non-breathable fabrics or ill-fitting bras can increase the risk of chafing, particularly when sweat or movement is involved. In breastfeeding individuals, friction can also occur due to poor latching technique, improper positioning, or prolonged feeding sessions, all of which place repeated mechanical stress on the nipple. Over time, this friction can lead to soreness, cracks, or fissures. This may mean those cracks become entry points for infection if not properly managed.^1,9

What is hyperkeratosis of the nipple during pregnancy and breastfeeding?

Hyperkeratosis of the nipple during pregnancy and breastfeeding is a benign condition characterised by thickening of the nipple skin due to an overproduction of keratin. It often presents as a rough, dry, or hardened patch on the nipple or areola, which may be mistaken for a wart or a callus. Though it’s not dangerous, this buildup can be uncomfortable and may interfere slightly with breastfeeding if severe. The exact cause isn’t fully understood, but hormonal changes during pregnancy and lactation are believed to play a role.^10,11

Summary

Nipple fissures are painful cracks in the skin of the nipple, commonly affecting breastfeeding individuals and athletes. They are most frequent during the second to third week postpartum and can lead to complications like infections if left untreated.

The most common cause is breastfeeding, especially when the baby has a poor latch or is improperly positioned. Prolonged or frequent feeding, incorrect use of breast pumps, and conditions like engorgement or mastitis can also contribute to nipple damage.

Friction from tight or rough clothing, especially during physical activities like running or surfing, can cause irritation known as “jogger’s nipple.” Improper nursing pads may also trap moisture and lead to cracking. Skin conditions such as eczema, Psoriasis, and infections can dry or inflame the nipple, increasing the risk of fissures. Other possible causes include rare conditions like Paget’s disease of the breast, as well as benign issues like nipple dermatitis or hyperkeratosis during pregnancy and breastfeeding.

Identifying the specific cause is essential for proper treatment and prevention.