Tag: symptoms

Subareolar Abscesses

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Subareolar abscesses:
    • Are a common type of nonlactational abscess
  • The pathophysiology:
    • Is believed to be keratin plugging of the lactiferous ducts:
      • Resulting in squamous metaplasia
    • The periductal inflammation that results can progress to abscess formation
  • A nipple cleft is an anatomic variant that seems to be associated with the condition:
    • Also known as Zuska’s disease
  • Because of their chronic nature including the formation of fistulas:
    • Their management involves different considerations than the management of lactational abscesses
  • Aspiration:
    • Is an appropriate practice for initial management of small non-loculated lactational and nonlactational abscesses
  • When aspiration is possible:
    • More invasive and painful procedures such as incision and drainage with postoperative daily wound packing are less appropriate as an initial step:
      • However, an abscess managed with aspiration may require serial procedures
  • Data from several small studies have demonstrated that:
    • Between 37% and 60% of abscesses will require more than one aspiration procedure
  • Aspiration is less likely to be successful for:
    • Larger abscesses
    • Multiloculated abscesses
    • Abscesses with a delay in presentation greater than 6 days
  • Antibiotics:
    • Should always be prescribed, and the likelihood of MRSA should be taken into account when choosing an initial antibiotic until culture results are available
    • Recurrent subareolar abscesses:
      • May also require anaerobic antibiotic coverage
        • For example, trimethoprim-sulfamethoxazole prescribed with metronidazole may be a good initial choice
    • Only a minority of abscesses are treated successfully with antibiotics alone without a drainage procedures
  • Surgical excision of a chronic subareolar abscess cavity:
    • May be indicated to prevent repeated episodes and there has been debate over the most appropriate specific technique
    • Removal of the terminal ducts appears to be an important step in decreasing recurrences
    • Therefore, procedures that remove only the abscess cavity but do not remove these ducts and the fistula tract will be less successful
    • Radial elliptical incision of the involved ductal tissue and fistula tract, including excision of the central nipple, so as to include the nipple cleft in the excision, has been shown to have a high rate of success
    • Removal of the terminal ducts through a periareolar incision, also called Hadfield’s procedure, has had a higher recurrence rate in small case studies
    • Ultrasound-guided percutaneous needle electrolysis causing tissue ablation within the fistula is an experimental procedure
  • Smoking is a risk factor for development of subareolar abscesses, and smoking cessation should be encouraged:
    • However, smoking is not a contraindication to surgery and should not be a barrier to proceeding
  • References
    • Snider HC. Management of mastitis, abscess, and fistula. Surg Clin North Am. 2022;102(6):1103-1116. doi:10.1016/j.suc.2022.06.007
    • Lam E, Chan T, Wiseman SM. Breast abscess: evidence based management recommendations. Expert Rev Anti Infect Ther. 2014;12(7):753-762. doi:10.1586/14787210.2014.913982
    • Barron AU, Luk S, Phelan HA, Williams BH. Do acute-care surgeons follow best practices for breast abscess management? A single-institution analysis of 325 consecutive cases. Journal of Surgical Research. 2017;216:169-171. doi:https://doi.org/10.1016/j.jss.2017.05.013
    • Naeem M, Rahimnajjad MK, Rahimnajjad NA, Ahmed QJ, Fazel PA, Owais M. Comparison of incision and drainage against needle aspiration for the treatment of breast abscess. Am Surg. 2012;78(11):1224-7. 
    • David M, Handa P, Castaldi M. Predictors of outcomes in managing breast abscesses-a large retrospective single-center analysis. Breast J. 2018;24(5):755-763. doi:10.1111/tbj.13053