Reassurance and Observation Without Intervention
For a 13-year-old with a congenitally inverted nipple that has been present since birth and shows no signs of infection, drainage, or pain, no treatment or imaging is indicated—this is a benign anatomical variant requiring only reassurance.
Understanding the Clinical Presentation
This presentation describes a congenital inverted nipple, not nipple discharge or an acute pathologic process. The key distinguishing features are:
- Present since birth (congenital anatomical variant)
- No discharge (neither physiologic nor pathologic)
- No signs of infection, inflammation, or pain
- Stable appearance over 13 years
The term "a little open" likely refers to the inverted appearance rather than any pathologic opening or discharge 1, 2.
Why No Intervention Is Needed
Age and Cancer Risk
- Breast cancer incidence in women under 30 years is 0.4% or lower, making malignancy concerns essentially irrelevant in this age group 3
- The ACR guidelines specifically state that imaging is not indicated for benign breast conditions in adolescents without pathologic features 3
Benign Nature of Congenital Inverted Nipples
- Congenital inverted nipples are present in approximately 2-10% of women and represent a normal anatomical variant 1, 2
- They are classified into grades I-III based on severity, with grade I being easily manually everted and grade III being difficult to evert 4
- Without associated symptoms (pain, discharge, infection, or recent change), these require no medical intervention 1, 2, 4
What to Monitor
Provide reassurance but educate the patient and family to return if any of the following develop:
- Development of spontaneous nipple discharge (particularly if bloody, serous, or from a single duct) 5, 6
- New breast mass or asymmetry 5
- Signs of infection (redness, warmth, purulent drainage, pain) 3
- Recent change in nipple appearance (new inversion in a previously normal nipple would be concerning) 6
- Skin changes (dimpling, peau d'orange, ulceration) 3
Future Considerations
If Correction Is Desired Later
- Surgical correction is elective and cosmetic in asymptomatic congenital inverted nipples 1, 2, 7
- Multiple surgical techniques exist with varying success rates and preservation of lactiferous ducts 8, 4
- Duct-preserving techniques have lower recurrence rates (0.6%) compared to duct-damaging techniques (9.9%) and should be preferred if surgery is pursued 8
- Correction can be delayed until after childbearing if breastfeeding preservation is a priority 2, 8
Functional Impact
- Grade I-II inverted nipples may still permit breastfeeding, while grade III typically cannot 4
- No intervention is needed unless the patient experiences functional problems (difficulty with breastfeeding in the future) or significant psychological distress 1, 2
Common Pitfalls to Avoid
- Do not confuse congenital inverted nipples with pathologic nipple discharge—the guidelines on nipple discharge evaluation 3, 5, 6 do not apply to this clinical scenario
- Do not order imaging (ultrasound, mammography) for an asymptomatic congenital inverted nipple in an adolescent 3
- Do not refer to surgery unless there is functional impairment or significant psychological distress affecting quality of life 8
- Avoid creating anxiety about a benign anatomical variant that has been stable since birth