Nipple problems

The Modernising Patient Pathway Symptomatic Breast Speciality Group has been established to support and look at new innovative ways to develop delivering Symptomatic Breast services across NHS Scotland.

Through development of Once for Scotland approaches for delivery of care, focus is being placed on looking at opportunities to develop clinical pathways to reduce unwarranted variation in delivery of quality healthcare and to sustainably improve waiting times for non-urgent care within breast services. Speciality Delivery Groups have been established to engage and fully utilise the role of clinical leadership across NHS Scotland.

Development of the Nipple Problems Pathway has been progressed through MPPP speciality group as was a common theme identified during meetings held with colleagues across NHS Scotland.

The recommendations have not followed the standard process used by SIGN to and are based on available guidance and expert opinion, with peer review to provide quality assurance.

This guidance will be reviewed and updated as new evidence emerges.

Consensus

A common theme during the Breast Speciality Delivery group meetings has focused on the referral
of women with nipple issues to secondary care services.

A consensus was formed around the principles that:

The majority of nipple issues are innocent and most can be managed without referral to
secondary care.

1. Eczema of the breast is common and often presents with itch, redness, skin thickening and scaling of the skin, often affecting the areola. The skin can become raw and weep. This should be distinguished from discharge from the milk ducts of the nipple.

1. It can be managed as eczema elsewhere on the body.
2. If cases fail to settle with local steroid or similar changes are present affecting the nipple itself, patients should be referred to exclude Paget’s Disease of the nipple.
3. If there is doubt in the breast clinic as to the nature of a skin issue, a punch biopsy should be performed.

2. Benign nipple inversion is common and often unilateral.

1. Slit-like or reversible nipple inversion is due to normal elasticity of the milk ducts or benign duct ectasia. It does not require further investigation or referral to secondary care.
2. Benign nipple inversion may be associated with apparent nipple discharge, either due to duct ectasia or retained shed skin cells. This does not need further investigation or specific management (see below).
3. Surgical correction of benign nipple inversion is specifically not recommended under the Exceptional Aesthetic Referral Pathway as it frequently recurs.
4. New persistent nipple inversion should prompt secondary care referral to exclude an underlying cancer.

3. Nipple discharge is usually innocent.

1. Bilateral or multiple duct discharge is either physiological or due to innocent duct ectasia. Further investigation or referral to secondary care are not required.
2. Discharge warranting referral and further investigation emerges from a single duct and is serous or bloodstained or bloodstained from multiple ducts. About 95% of such cases are innocent (usually due to intraduct papilloma or duct ectasia). Approximately 5% are caused by DCIS.
3. If apparently benign discharge is very troublesome, surgical duct excision is considered but does result in a numb nipple and will not permit subsequent breast feeding.

4. Mammography is recommended as part of standard one stop triple assessment in those with single duct serous or bloodstained nipple discharge aged over 40. Ultrasound of ducts deep to nipple area should be performed in such cases if duct excision is not planned.

Surgical management

Duct excision should be considered for those with single duct, blood-stained or serous nipple discharge due to the low risk (~5%) of incidental DCIS.

Duct excision may be considered for symptomatic relief of discharge that is frequent and troublesome.

 Decisions on whether a single duct (microdochectomy) or all ducts should be excised will vary from patient to patient depending on factors including age, plans for future breast feeding, confidence in sampling correct duct and likelihood of recurrence of discharge after microdochectomy for duct ectasia with increased risk to nipple blood supply with repeat surgery.

Nipple eversion surgery is specifically not recommended in the Scottish Exceptional Aesthetic Referral Pathway.

Scottish Referral Guidelines for Suspected Cancer. www.cancerreferral.scot.nhs.uk

ABS Summary statement: Guidelines for the investigation and management of spontaneous nipple discharge in the absence of a breast lump. www.associationofbreastsurgery.org.uk

Exceptional Referral Protocol 2019 CMO(2019)05 - Exceptional Referral Protocol (previously known as the Adult Exceptional Aesthetic Referral Protocol) – refresh April 2019 (scot.nhs.uk)

   gjnh.cfsdpmo@gjnh.scot.nhs.uk

  www.nhscfsd.co.uk

@NHSScotCfSD

Centre for Sustainable Delivery

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