Nipple conditions

Nipple and skin changes of the breast

Eczematous changes

Dermatitis commonly affects the areola or breast skin and spares the nipple, can be bilateral and often responds to topical eczema treatments, such as low dose steroids. Skin conditions that are affecting the breast in addition to other areas of the body do not need referral to the breast care centre, but may require dermatology referral if not responding to primary care management.

Paget’s disease of the breast commonly affects the nipple first and then the areola. More commonly unilateral, and can be associated with ulceration of the nipple. This doesn’t respond to topical treatments. Needs 2ww referral if suspected. Usually try topical treatments first and refer if doesn’t respond, unless very high suspicion of malignancy.

Nipple retraction

Can be physiological and age related (duct ectasia causes a slit like retraction).

Intermittent nipple retraction is likely to be physiological, as are inverted nipples that can be easily everted.

If nipple inversion is unilateral, recent, associated with other symptoms such as ulceration or an inability to evert the nipple, these warrant a 2ww referral.

Skin changes

The skin of the breast can be affected by any skin conditions that present elsewhere on the body, and most of these do not require referral to the breast care centre. Understandably patients get concerned that these may be a sign of breast cancer.

Worrying signs;

• Dimpling
• Breast contour changes
• Significant new asymmetry
• Oedematous changes/ peau d’orange
• Breast skin changes on previous breast cancer patients

Anti-fungals are very rarely indicated for breast related skin changes, aside from breast feeding mothers with lactation associated thrush, intertrigo underneath the breasts (as per any other skin crease/fold area on the body) or rarely immuno-compromised patients.

Erythema on the breast

Breastfeeding, smoking and diabetes as well as patients who are relatively immunosuppressed (long term steroids, etc) are more likely to develop infections affecting the skin or breast tissue. If these do not resolve with a course of antibiotics, these warrant a referral to the breast clinic. If you are concerned there may be an underlying abscess (especially in women breast feeding), please contact the breast care centre for an appointment in the next 24-48 hours. Please see the mastitis and breast abscess page on Remedy for more information. 

Nipple discharge

Nipple discharge without a palpable breast mass is a poor indicator of malignancy (incidence approx. 3%)

Causes of bilateral multi-duct discharge (which usually does not need require referral to the breast care centre);

Premenopausal women;

• Benign physiological secretions (often white)
• Periductal mastitis (often seen in smokers) – associated with erythema and often a discharging sinus
• Duct ectasia – often clear / green secretions

 Post-menopausal;

• Duct ectasia (normal age related change of subareolar ducts)

Galactorrhoea;

• Can occur after finishing breast feeding for up to 2 years.
• Often drug related
• May be due to hypothyroidism
• Rarely due to an pituitary adenoma

Bloody discharge in pregnancy;

• Can occur in 2^nd/3^rd trimester due to epithelial proliferation.
• If no other clinical concerning findings (mass etc) patient should be reassured and re-evaluated 2/12 post-partum

Red Flags

2ww referral indications

• Unilateral skin changes affecting the nipple (not areola)
• Unilateral skin changes that have not responded to a course of topical eczema treatment
• New unilateral asymmetrical nipple retraction/inversion
• Signs of unilateral oedema, thickening or erythema in the breast especially when no obvious signs of infection, or not responded to a course of antibiotics.
• Spontaneous, unilateral or bloody nipple discharge (please note that many women can express small amounts of discharge from their nipples if they squeeze the nipple / breast tissue. This is not an indication for referral – only spontaneous discharge)

Non urgent referral criteria – Profuse, bilateral, symptomatic nipple discharge, which is coming through to clothes. 

Before referral

History; key information to ask:

• Unilateral/bilateral
• One duct or multiple
• Duration of symptoms
• Frequency of discharge
• On expression/spontaneous (does patient notice in clothes etc)
• Colour of discharge
• Associated symptoms; pain, erythema of skin, mass, skin changes

General;

• Menopausal status; if pre-menopausal, where are they in their cycle?
• Currently pregnant or breastfeeding?
• Previous pregnancies?
• On any hormonal medication; contraception/HRT?

 Relevant PMH and DH

• Smoker?
• Last mammogram if had one
• Personal history of breast or ovarian cancer; when, which side and treatments undergone
• Family history of breast/ovarian cancer

 Examination;

 Carry out a normal breast examination

• Discharge reproducible on examination? Single or multiple ducts, colour
• Note any breast masses
• Axillary masses, ipsilateral or contralateral side
• Skin Changes; redness, dimpling, asymmetry, appearance of oedema, rashes
• Other nipple changes; retraction, eczematous like changes

Services

Refer to the Bristol Breast Care Centre using the 2WW referral form

Resources

Useful patient information;

duct ectasia (BCC82) - Benign breast conditions information provided by Breast Cancer Now

periductal mastitis (BCC154) - Benign breast conditions information provided by Breast Cancer Now

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