Treatment of Chronic Granulomatous Mastitis
For chronic granulomatous mastitis, treatment should be guided by symptom severity using a staged approach: mild cases can be observed or treated with NSAIDs, moderate cases require immunosuppression (primarily corticosteroids or intralesional steroid injections), and severe cases with abscess formation or refractory symptoms need surgical excision combined with immunosuppressive therapy. 1, 2
Initial Assessment and Diagnosis Confirmation
Before initiating treatment, confirm the diagnosis through core needle biopsy showing non-caseating granulomas with giant cells, epithelioid cells, and chronic inflammatory infiltrate, while excluding infectious causes (tuberculosis, fungal infections) and malignancy 1, 3. The condition predominantly affects premenopausal women of childbearing age, often within 1-4 years of pregnancy and lactation, with Hispanic ethnicity being a notable demographic factor 2, 4.
Critical pitfall: Do not treat as simple bacterial mastitis with antibiotics alone—this approach fails in the majority of cases and delays definitive treatment 5. However, if abscess is present, antibiotics should be administered before starting immunosuppressive therapy 4.
Symptom-Based Treatment Algorithm
Mild Symptoms (Minimal Pain, No Abscess, Small Lesion)
- Observation alone is appropriate for 4.5% of patients with minimal symptoms 2
- NSAIDs can provide symptomatic relief and achieved resolution in 3% of cases 3
- Monitor closely for progression over 4-8 weeks 1
Moderate Symptoms (Significant Pain, Inflammation, Mass Without Abscess)
- Systemic corticosteroids are the mainstay, successfully treating 43% of patients 3
- Intralesional steroid injections are highly effective and were used in 43 of 83 patients receiving immunosuppression 2
- Continue immunosuppressive therapy until complete remission to prevent recurrence rates up to 50% 4
- Immunosuppression predicts symptom improvement or resolution at 1 month (odds ratio 4.22) 2
Severe Symptoms (Abscess, Skin Ulceration, Fistula Formation, Refractory Disease)
- Surgical excision is indicated, performed in 5.4-11% of cases initially and required in 16 additional patients after recurrence 2, 3
- Patients with severe symptoms are significantly more likely to require surgical intervention (21.4% vs. 0-7.5% for mild/moderate symptoms) 2
- Combination therapy (surgery plus immunosuppression) was used in 19.6% of cases 2
- Complete excision is essential to minimize recurrence 4
Expected Outcomes and Timeline
The majority of patients (75.9%) experience symptom improvement or resolution within 1 year, with median time to improvement of 3 months 2. Physician-assessed cosmesis at 1 year is excellent or good in 57.1% of cases and is not significantly associated with treatment type or initial symptom severity 2.
Recurrence occurs in 33% of patients, requiring second-line treatment: 30 patients achieved cure with additional medical therapy, 16 required excision, and 5 resolved with observation alone 3.
Important Clinical Considerations
Exclude inflammatory breast cancer if erythema covers at least one-third of the breast, peau d'orange is present, or symptoms persist beyond 1 week of appropriate antibiotics in non-lactating women 6. Urgent ultrasound and core needle biopsy within 48 hours are mandatory if malignancy is suspected 6.
Methotrexate and colchicine have been reported as alternative immunosuppressive options in refractory cases 4. The condition requires prolonged immunosuppressive therapy until complete remission to prevent the high recurrence rate 4.