What is the diagnosis and treatment for a 1 mm papule on the tip of the nipple with a white creamy discharge upon squeezing?

Diagnosis and Management of 1mm Nipple Papule with White Creamy Discharge

Most Likely Diagnosis

This presentation is most consistent with a blocked Montgomery gland (areolar gland) or a small keratin-filled epidermal inclusion cyst on the nipple, not true pathologic nipple discharge. The key distinguishing feature is that the discharge comes from a visible 1mm papule when squeezed, rather than from the ductal orifices within the nipple itself 1, 2.

Critical Distinction: This is NOT Nipple Discharge

• True nipple discharge originates from the lactiferous ducts within the nipple, not from a discrete papule on the nipple surface 1, 2
• The white creamy material expressed from a 1mm papule represents sebaceous/keratin material from a blocked gland or cyst, not ductal secretions 1
• Montgomery glands are sebaceous glands normally present on the areola that can become blocked and present as small papules with expressible white material 1

Management Approach

Conservative management with observation is appropriate, as this represents a benign dermal/glandular finding rather than pathologic nipple discharge:

Initial Management

• Reassure the patient and advise against squeezing or manipulating the papule, as this can cause inflammation and secondary infection 1
• Warm compresses may help if there is any associated discomfort 1
• The lesion will typically resolve spontaneously with cessation of manipulation 1

When to Consider Further Evaluation

• If the papule becomes inflamed, infected, or significantly enlarges, consider simple excision or incision and drainage 3
• If true spontaneous nipple discharge develops (fluid coming from the nipple ductal openings without manipulation), then formal evaluation for pathologic discharge is warranted 4, 2
• If a breast mass develops or the patient has other concerning breast symptoms, age-appropriate imaging (mammography/ultrasound for age ≥40 years, ultrasound for age <40 years) should be performed 4

What This is NOT

This presentation does NOT meet criteria for pathologic nipple discharge, which would require imaging evaluation:

• Pathologic discharge is spontaneous, unilateral, from a single duct, and serous or bloody 1, 2
• Physiologic discharge is bilateral, from multiple ducts, and white/green/yellow, occurring only with provocation 1, 2
• Neither category includes discharge from a discrete papule on the nipple surface 1, 2

Key Clinical Pitfall to Avoid

Do not order mammography or ultrasound for a small papule with expressible material on the nipple surface, as this is not true nipple discharge and does not warrant breast imaging 4, 1. Imaging is only indicated if true ductal discharge develops or other breast pathology is suspected 4.