Breast Abscess

Overview of Breast Abscess
A breast abscess is an infection in the breast. A non-lactational breast abscess is a breast abscess that occurs in a woman who is not pregnant or breastfeeding.

Non-lactational breast abscesses can be divided into two broad groups:  

  • Peripheral (away from the nipple or nipple areolar complex)  
  • Areolar (near or behind the nipple or nipple areolar complex) 

Most peripheral breast abscesses are similar to infections elsewhere in the body and are managed similarly. These peripheral breast abscesses may be associated with underlying medical issues such as diabetes, or skin conditions like hidradenitis (clogged sweat glands), acne or trauma.

Areolar breast abscesses most commonly affect women 18-50 years.  They are seen more often in smokers, obese patients and in patients with nipple piercing.  They are somewhat more common in African Americans. A central cleft in the nipple is often seen in patients with areolar breast abscesses.

Patients who are diabetic or who smoke are also more likely to develop recurrent abscesses.

Causes of Breast Abscess
Subareolar abscesses may be caused by changes in the terminal ducts underneath the nipple. Cells may undergo “squamous metaplasia”, or flatten out, plugging up the ducts and obstructing them. This leads to a buildup of debris and secretions which become infected.

The most frequent organisms seen are aerobic organisms, bacteria that live with oxygen, like Staph aureus, streptococcus and pseudomonas. Infections can also involves anaerobic bacteria, bacteria that live without oxygen, such as peptostreptococcus, propionibacterium and bacteroides.

Signs and Symptoms of Breast Abscess
Patients most commonly present with pain, tenderness and swelling.  The area may be red as well. Any change in the breast should be addressed with a medical professional.

Management of Breast Abscess
Management of abscess generally starts with the least invasive treatment. Patients are often placed on broad spectrum antibiotics which cover the most common organisms involved.

An ultrasound of the affected area can show if there is a collection of fluid.  If so, the fluid can be aspirated (removed with a needle).  Aspiration can provide material for culture as well as treat the abscess, This treatment will often lead to decreased pain, pressure and swelling.  If the fluid is thick, vacuum-assisted core biopsy and aspiration may be helpful. Sometimes, repeated aspirations are necessary

If the skin over the abscess is too thin or compromised, then opening the abscess, known as an incision and drainage, may be necessary.  The wounds may often be left open, with gauze packing changes done daily to allow closure from the bottom up.

Most breast abscesses will resolve with needle aspiration or incision and drainage. Recurrent and chronic abscesses are most commonly associated with smoking. 

If a subareolar abscess recurs and a duct fistula (draining opening or sinus tract) develops, surgery is required. Duct excision, removal of the duct, sinus tract and inflamed tissue, after the infection has resolved is frequently necessary. Stopping smoking is also critical to prevention of recurrent abscesses.

Rarely, breast cancers may present as an abscess. For this reason, breast surgeons will biopsy abscess cavities in certain patients with breast abscesses.