What is the differential diagnosis for breast pain with small white bumps?

Differential Diagnosis for Breast Pain with Small White Bumps

The most likely diagnosis is Montgomery tubercles (normal sebaceous glands on the areola) or blocked sebaceous glands/milia, which are benign findings that require only reassurance and symptomatic management if the clinical breast exam is otherwise normal. 1

Primary Differential Diagnoses

Benign Physiologic Conditions (Most Common)

• Montgomery tubercles: Normal sebaceous glands on the areola that appear as small white or flesh-colored bumps, often more prominent during hormonal fluctuations, pregnancy, or lactation 1
• Blocked sebaceous glands/milia: Small white bumps (1-2mm) caused by trapped keratin, commonly occurring on breast skin, completely benign 1
• Cyclic mastalgia with sebaceous prominence: Breast pain related to menstrual cycle (70% of breast pain cases) with concurrent prominence of normal sebaceous structures 1, 2

Infectious/Inflammatory Causes

• Folliculitis: Inflammation of hair follicles presenting as small white pustules with surrounding erythema and focal pain, may precede induration and warmth 1
• Mastitis: Focal pain that may precede induration, redness, warmth, and fever; can present with skin changes including pustular lesions 1
• Periductal inflammation: Burning pain behind nipple with skin changes, particularly in smokers 1, 2

Dermatologic Conditions

• Paget's disease of the nipple: Rare malignancy presenting with eczema-like changes, bleeding, ulceration, and itching of the nipple-areolar complex; diagnosis often delayed due to confusion with benign dermatologic conditions 1
• Eczema/dermatitis: Inflammatory skin condition causing white scaling, crusting, and pain 1

Malignant Considerations (Low Probability)

• Invasive lobular carcinoma: Disproportionately associated with mastalgia compared to other cancer types, though pain as sole symptom carries only 1.2-6.7% cancer risk 1
• Inflammatory breast cancer: Can present with skin changes including peau d'orange appearance and pain, though typically with more dramatic findings 1

Diagnostic Approach Algorithm

Step 1: Clinical Breast Examination

• Assess for palpable mass, asymmetric thickening, nipple discharge, or skin changes beyond the white bumps 1
• Determine pain characteristics: cyclic vs. noncyclic, focal vs. diffuse, relationship to menses, duration, impact on daily activities 1
• Examine the white bumps specifically: location (areolar vs. breast skin), size, distribution, presence of inflammation or discharge 1

Step 2: Risk Stratification for Imaging

No imaging needed if: 2, 3

• White bumps are consistent with Montgomery tubercles or sebaceous glands on areola
• Pain is cyclic/diffuse and nonfocal
• No palpable abnormality on exam
• Screening mammograms current and negative
• Action: Reassurance and symptomatic management resolve symptoms in 86% of mild cases and 52% of severe cases 2

Imaging indicated if: 1

• Pain is focal and persistent
• Any palpable mass or asymmetric thickening
• Skin changes suggesting infection or malignancy (beyond normal sebaceous structures)
• Postmenopausal presentation with new-onset symptoms
• Age ≥30 years: Diagnostic mammogram with or without ultrasound 1
• Age <30 years: Ultrasound alone 1

Step 3: Further Workup Based on Imaging

BI-RADS 1 (negative): 1

• Symptomatic management only
• Reassurance regarding benign nature of white bumps

BI-RADS 2-3 (benign/probably benign): 1

• If simple cyst correlates with focal pain, consider drainage for symptom relief
• Complicated cysts: imaging every 6 months for 1-2 years with symptomatic management

BI-RADS 4-5 (suspicious/highly suggestive of malignancy): 1

• Core needle biopsy preferred
• If skin changes persist with negative breast imaging, punch biopsy of skin or nipple biopsy required to exclude Paget's disease

Management Recommendations

For Benign Findings (Montgomery Tubercles/Sebaceous Glands)

• Reassurance is therapeutic: Explain these are normal anatomic structures 1, 2
• Avoid manipulation: Do not squeeze or attempt to express contents, which can cause infection 1
• Symptomatic pain management: 1, 2
  • Well-fitted supportive bra
  • Over-the-counter NSAIDs (ibuprofen)
  • Ice packs or heating pads
  • Regular physical exercise

For Suspected Infection

• Do not delay diagnostic evaluation with empiric antibiotics 1
• Antibiotics may be given based on clinical suspicion, but biopsy should proceed if imaging shows suspicious findings 1

Critical Pitfalls to Avoid

• Never dismiss focal, persistent breast pain without proper evaluation, even when white bumps appear benign, as some cancers (especially invasive lobular and anaplastic carcinomas) can present with pain 1, 4
• Do not assume white bumps are always benign without examining for associated concerning features (ulceration, bleeding, eczematous changes suggesting Paget's disease) 1
• Avoid unnecessary imaging for diffuse, nonfocal pain with clearly benign sebaceous structures when clinical exam is otherwise normal, as this increases subsequent clinical visits without improving outcomes 3
• Never rely solely on negative mammography to exclude Paget's disease if nipple/areolar skin changes are present; skin biopsy is required 1
• Do not fail to consider extramammary causes (costochondritis, nerve entrapment, referred cardiac/GI pain) when breast exam and imaging are normal but pain persists 1, 2