Acute painful breast in a non-lactating womanBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2646 (Published 15 June 2016) Cite this as: BMJ 2016;353:i2646
- Jessamy Bagenal, editorial registrar and specialty registrar in general surgery1,
- Janani Bodhinayake, general practitioner2,
- Kathryn E Williams, specialty registrar in general surgery and national TIG oncoplastic fellow3
- 1BMJ Editorial, BMA House, London WC1H9JR, UK
- 2University College London, London, UK
- 3University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
- Correspondence to: J Bagenal
What you need to know
Uncomplicated mastitis can be managed in the community
Offer admission and urgent referral to a general surgeon to patients with abscess, sepsis, haemodynamic instability, or mastitis with immunocompromise
Offer outpatient referral for a cancer appointment to those with suspected inflammatory breast cancer or those whose symptoms fail to resolve
A 50 year old woman describes a three day history of a painful right breast.
Non-lactating women may present with a painful red breast because of periductal inflammation, which can evolve into a breast abscess. This condition must be differentiated from inflammatory breast cancer, a rare type of breast cancer that mimics the signs and symptoms of mastitis (table 1⇓).
Smoking is the main predisposing factor for periductal mastitis due to ductal damage (relative risk from 6.2 to 26.4 for heavy smokers).1 2 3 There is usually an infective element; commonly Staphylococcus aureus, enterococci, or Bacteroides. Poor hygiene and lower socioeconomic status are associated with breast abscess.4
What you should cover
Pain of mastitis typically starts over hours to days—typical symptoms are pain, redness, and fever.
Unilateral, subareolar, or periductal distribution is typical of mastitis (see fig 1⇓). Inquire about symptoms that may drive onwards referral by indicating that the patient is systemically unwell or unstable—such as tachycardia and pyrexia.
Be alert to symptoms that might suggest an alternate diagnosis; for example, itching may suggest a dermatological cause.5 Inquire about longstanding symptoms or weight loss that might suggest a malignant process.6
Explore risk factors such as smoking. Patients with diabetes, rheumatoid arthritis, corticosteroid treatment, or HIV infection or other immunocompromise are thought to be at increased risk, although the vast majority of women presenting with periductal mastitis do not have these identifiable risk factors and the cause is unknown.
Ask about local factors that may increase the risk of mastitis. Nipple piercing may damage subareolar ducts, resulting in mastitis. Skin conditions such as eczema may provide a route of entry for bacteria,4 which more commonly leads to cellulitis rather than mastitis.
Inquire about underlying breast abnormality such as cysts or previous episodes of mastitis or abscess.
Examine both breasts, the axillae, and supraclavicular area.
Ask the patient to raise her arms and compare the breasts. Note skin tethering, asymmetry, nipple inversion, oedema of the skin giving an “orange peel” appearance and dimpling, which may suggest breast cancer. Observe the distribution of erythema and any associated discharge or ulceration. Periductal mastitis will typically form a wedge shape (fig 1⇑).4
Palpate the breast. In mastitis, the overlying skin is usually warm. A focal, fluctuant swelling suggests an abscess (fig 2⇓). Note any other breast masses or lymphadenopathy. Note their location, size, mobility, consistency, and relation to surrounding structures, including fixation to skin or muscle.
Perform a basic set observations such as pulse rate, blood pressure, and temperature to help gauge how systemically unwell the patient is.
What you should do
The management below is based on NICE guidelines,5 which are extrapolated from WHO recommendations, expert opinion, and guidance about the more common scenario of lactational mastitis. Table 2⇓ summarises the management options.
Offer urgent referral to a breast or general surgeon to patients with
In these patients, basic blood tests may be offered as well as an ultrasound scan and mammogram. Ultrasound guided aspiration or mini-incision and drainage over the thinnest part of the abscess is best practice, and is normally performed through a breast department.
Management of uncomplicated mastitis can begin in primary care. Offer analgesia and advise the patient to use a warm compress to alleviate tenderness. Prescribe an empirical antibiotic regimen such as oral co-amoxiclav for 10-14 days. For penicillin-allergic patients, a combination of clarithromycin or erythromycin with metronidazole is a reasonable choice.1 4 7 8
Changes to the breast are worrying for patients, and it is important to be sensitive to this. Reassure patients that they can expect their breast to return to normal shape and size.7 Arrange follow-up within two weeks to reassess and ensure resolution. If predisposing factors such as nipple piercing, skin conditions, or smoking are identified, offer advice on their management with a view to reducing the chance of recurrence. Advise patients to seek medical advice if symptoms worsen or are not resolving by 48 hours. At this point, consider an alternative diagnosis such as inflammatory breast cancer and Paget’s disease and referral to secondary care. Consider referral for patients with any concerning features such as an underlying mass, mastitis that fails to resolve with a course of antibiotics, or weight loss for a suspected cancer appointment with a general surgeon or breast specialist.9
Education into practice
Are women with breast problems taught breast self examination at your clinic?
How patients were involved in the creation of this article
No patients were involved in the creation of this article
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned, externally peer reviewed.