Periductal mastitis is an inflammation that develops outside the breastfeeding period and involves the tissue around the milk ducts just behind the nipple. The disease begins in the nipple region; inflammation arises in the tissue surrounding the ducts and, over time, a painful swelling, an abscess or a tract opening onto the skin may form.
Smoking is the factor most strongly associated with this condition. It is thought that smoking damages the ducts behind the nipple and makes the area prone to infection. For this reason the disease follows a different mechanism and course from mastitis related to breastfeeding.
Although it can initially be brought under control with antibiotics, inflammation may return in the same area after treatment, and surgery comes into question in recurrent cases. This page summarises the symptoms, diagnosis and treatment options in broad terms; for a personal assessment, a breast specialist should be consulted.
Symptoms
In periductal mastitis, the complaints are mostly concentrated around the nipple and areola. Patients usually notice a painful, red swelling in this area, and the complaints may disappear and return at intervals.
- Pain, redness and warmth around the nipple
- A tender, palpable mass at the edge of the areola
- Nipple retraction or a change in its shape
- A foul-smelling, thick or purulent discharge from the nipple
- A tract (fistula) opening onto the skin around the areola that drains repeatedly
Fever is usually less marked than in mastitis during breastfeeding. When an abscess develops, the swelling enlarges, pain increases and the area feels fluctuant. Repeated swelling or discharge in the same area suggests that the disease has come back after earlier treatment.
Diagnosis
In diagnosis, the history of the complaints, smoking and earlier similar attacks are important to ask about. On examination, the swelling around the nipple, redness, discharge and the opening of any fistula are assessed.
Ultrasound is the most commonly used method to show inflammation around the ducts and an abscess collection; it also guides drainage. Depending on the patient's age and the findings, additional imaging such as mammography or MRI may be requested.
- Bacteria cultured from an abscess or discharge sample can help to determine the appropriate antibiotic.
- Dilated milk ducts (duct ectasia) may be seen on ultrasound and can be present together with the disease.
- If imaging raises suspicion of cancer, or if the lesion does not regress with treatment, a biopsy and pathological examination must be performed.
Because recurrent inflammation near the nipple can rarely be confused with other diseases, further tests should be considered in every case that does not respond to treatment.
Treatment
The treatment plan is determined by the doctor according to the stage of the inflammation and whether an abscess is present. If there is no abscess yet, symptoms can regress in many cases with antibiotic treatment and pain control; the choice and duration of medication are adjusted for each person.
- If an abscess is found on ultrasound, it needs to be drained; small abscesses can be drained with a needle, while large or recurrent abscesses may be drained through a small incision.
- After drainage, antibiotic treatment is continued, and wound care and a follow-up visit are planned.
- Quitting smoking is an important part of treatment for lowering the risk of recurrence, and support can be sought for this.
- In patients with recurrent abscesses or a fistula, surgical removal of the affected ducts behind the nipple (duct excision) may be recommended.
Even after surgery, the disease can reappear after some time. For this reason, the outcomes, possible recurrence and the appearance of the nipple should be discussed in detail with the doctor before the operation, and regular follow-up should be carried out afterwards.
For more detail on surgical options and the surgical process, see the Breast surgery page.
