Incision and Drainage for Nipple Abscess
Yes, incision and drainage (I&D) is appropriate for nipple abscesses, but simple I&D alone is insufficient for subareolar/retroareolar abscesses—these require excision of the obstructed central ducts to prevent recurrence. 1, 2
Initial Management Approach
For acute nipple/subareolar abscess, perform I&D as the primary treatment, following the same principles as other skin and soft tissue infections. 3
- I&D is the cornerstone of treatment for any cutaneous abscess and is non-negotiable. 3, 4
- The incision should provide adequate drainage while minimizing cosmetic deformity. 3
- Thoroughly evacuate all pus and probe the cavity to break up loculations. 4
Critical Distinction: Peripheral vs. Subareolar Location
Peripheral Breast Abscesses
- Behave like standard soft tissue abscesses and resolve with drainage plus antibiotics. 5
- Simple I&D is adequate for peripheral locations. 5
Subareolar/Retroareolar Abscesses
- I&D alone will fail in 91% of cases due to the underlying pathology of obstructed terminal ducts. 1, 2
- These abscesses are caused by keratin plugging from squamous metaplasia of ducts, typically in women in their 30s who smoke or have congenitally cleft nipples. 5
- Definitive treatment requires excision of the central nipple ducts along with the obstructed ducts themselves. 1
- This achieves a 91% cure rate with 95% satisfaction in cosmetic outcome. 1
When to Add Antibiotics
Antibiotics are not routinely needed after adequate drainage unless systemic signs are present. 3, 4
Add antibiotics if any of the following exist:
- Temperature >38°C or <36°C 4
- Heart rate >90-100 beats/min 4
- WBC >12,000 or <4,000 cells/µL 4
- Surrounding cellulitis >5 cm 4
- Immunocompromised state 3
Empiric coverage should target both S. aureus (including MRSA) and streptococci. 4
Options include:
- Clindamycin 300-450 mg PO TID 3
- TMP-SMX 1-2 DS tabs PO BID 3
- Vancomycin 15-20 mg/kg IV every 8-12h for severe cases 3
Size-Based Treatment Algorithm
Abscesses <5 cm
- Consider needle aspiration with ultrasound guidance as first-line, especially for lactational abscesses. 6, 7
- This provides good cosmetic results and can be repeated if needed. 6
- 45% require multiple aspirations, but 41% ultimately fail and need I&D. 6
Abscesses ≥5 cm
- Proceed directly to I&D, as needle aspiration has high failure rates. 6
- Risk factors for aspiration failure include large diameter, large pus volume, and treatment delay. 6
Common Pitfalls to Avoid
Do not perform simple I&D for recurrent subareolar abscesses—this leads to multiple scars, nipple distortion, and continued recurrence without addressing the obstructed ducts. 1, 2
Do not attempt needle aspiration alone for abscesses >5 cm—success rate is only 25% overall and <10% with MRSA. 4, 6
Do not give antibiotics without adequate drainage—studies show no benefit when source control is incomplete. 4
Special Considerations
Post-Nipple Piercing Abscesses
- Can occur 2 weeks to 17 months after piercing. 7
- Ultrasound typically shows complex or hypoechoic mass. 7
- Ultrasound-guided aspiration may be appropriate as an alternative to surgical evacuation. 7
Lactational Abscesses
- Needle aspiration is preferred for smaller abscesses to preserve cosmetic outcome. 6
- 70% of patients undergoing I&D are dissatisfied with cosmetic results. 6
Follow-Up Requirements
Re-evaluate at 7 days—persistent fever or failure to improve indicates inadequate source control requiring repeat imaging or intervention. 4
For recurrent subareolar abscesses, refer for definitive surgical excision of the central duct system rather than repeated I&D procedures. 1, 2