From the Guidelines
The management of periductal mastitis primarily involves addressing the underlying inflammation and infection, often requiring a combination of antibiotics, supportive care, and potentially surgical intervention. The condition is characterized by an exquisite continuous burning pain, usually behind the nipple, and a hypersensitive breast, with 25% of patients with noncyclical pain reported to have duct ectasia with periductal inflammation 1.
Key Considerations
- Periductal mastitis is often associated with heavy smoking, suggesting that smoking cessation is a crucial aspect of management.
- The condition can present with diffuse palpable nodularity, but there is no direct relationship between the extent of nodularity and the severity of pain.
- Initial treatment may include broad-spectrum antibiotics, although the specific choice and duration should be guided by the severity of the infection and the patient's overall health status.
- Supportive care, including pain management with analgesics and the use of warm compresses, can help alleviate symptoms.
Treatment Approach
- Antibiotics such as co-amoxiclav or clindamycin may be considered for initial treatment, targeting both aerobic and anaerobic bacteria 1.
- For severe cases or those with systemic symptoms, intravenous antibiotics may be necessary, highlighting the importance of early and appropriate intervention.
- Surgical management, including the excision of the affected duct system, may be necessary for recurrent or chronic cases, underscoring the need for a comprehensive treatment plan.
Lifestyle Modifications
- Smoking cessation is critical, as smoking is a significant risk factor for periductal mastitis and can impair healing 1.
- Breastfeeding women should continue to breastfeed or express milk from the affected breast to prevent milk stasis, which can worsen the condition, although specific guidance on periductal mastitis management in breastfeeding women may require further consideration.
From the Research
Management of Periductal Mastitis
The management of periductal mastitis involves various treatment options, including surgical and non-surgical approaches.
- Treatment failure rates (TFR) for different invasive treatment measures have been evaluated in a systematic review and meta-analysis 2.
- The study found that breast duct irrigation, a minimally invasive treatment, yielded good outcomes and may be considered as a first-line treatment for periductal mastitis patients 2.
- Minor excision methods, except for primary closure alone, may be sufficient for most periductal mastitis patients 2.
- Major excision, especially with radial incision, was found to be a highly effective salvage therapy 2.
- The major plastic surgery technique was also found to be an acceptable alternative treatment for patients with large lesions and concerns about breast appearance 2.
Surgical Treatment
Surgical treatment options for periductal mastitis include:
- Fistulectomy (Hadfield operation), which involves the total excision of the affected duct and the fistulous tract 3.
- Wide surgical excision, fistulectomy, and extended excision with transfer of a random breast dermo-glandular flap (BDGF) have been found to be effective surgical modalities for different types of periductal mastitis 4.
- Incision and drainage, and minor excision with primary closure alone should be avoided for periductal mastitis patients due to high treatment failure rates 2.
Non-Surgical Treatment
Non-surgical treatment options for periductal mastitis include:
- Broad-spectrum antibiotics, which have been used to treat all patients with periductal mastitis in some studies 5.
- However, surgery was necessary for most patients (91%) in one study, suggesting that non-surgical treatment may not be sufficient for all cases 5.
Factors Affecting Treatment Outcome
Factors that may affect treatment outcome for periductal mastitis include: