What is the best approach to manage a recurrent breast abscess?

Management of Recurrent Breast Abscess

For a recurrent breast abscess in the same location of the inner breast, definitive surgical excision of the abscess cavity along with the involved lactiferous duct is required to prevent further recurrence, as incision and drainage alone results in nearly 100% recurrence rates. 1, 2

Understanding the Pathophysiology

The key to preventing recurrence is understanding that recurrent subareolar and periareolar breast abscesses are caused by plugging of lactiferous ducts with keratin, leading to squamous metaplasia and chronic inflammation. 2 Simply draining the abscess without addressing the underlying plugged duct guarantees recurrence. 2

Initial Diagnostic Steps

• Send aspirate for both culture AND cytology to rule out underlying malignancy, particularly in postmenopausal women, as squamous cell carcinoma can present as a breast abscess. 3
• Perform mammography in patients over 30 years old to exclude underlying pathology. 4
• Obtain ultrasound imaging to define the extent of the abscess and identify any associated fistulous tracts or additional collections. 4

Definitive Treatment Algorithm

For First Recurrence:

• Perform en bloc excision of the abscess cavity plus the plugged lactiferous duct under antibiotic coverage—this approach achieves zero recurrence when properly executed. 2
• If a chronic fistulous tract is present (identified in approximately 46% of cases), excise the fistula, its feeding abscess, and the plugged lactiferous duct together. 2

For Multiple Recurrences or Bilateral Disease:

• Consider en bloc resection of all subareolar ampullae if recurrence occurs in a different duct after initial surgical excision, as this prevents formation of new abscesses in adjacent ducts. 2

Surgical Technique Considerations:

• Excision should include the abscessed ampulla with its proximal plugged duct, not just the abscess cavity itself. 2
• Primary closure with cavity obliteration under antibiotic cover can reduce morbidity compared to traditional open drainage. 5

When Temporizing Measures Are Acceptable

Needle aspiration plus antibiotics may be attempted only for first-time abscesses <3 cm, but this carries a recurrence risk and should not be used for already-recurrent disease. 6, 4

• Abscesses >3 cm require catheter drainage if a conservative approach is chosen. 4
• Multiple aspirations (average 2.4 procedures) are typically needed, and approximately 14% still require eventual surgery. 6

Critical Pitfalls to Avoid

• Never perform simple incision and drainage for recurrent breast abscess—this has a 100% recurrence rate and only provides temporary relief. 1, 2
• Do not rely on antibiotics alone—all four cases treated with antibiotics only in one series recurred. 2
• Always biopsy the abscess cavity wall if surgical drainage is performed to exclude malignancy. 3
• Recognize that bacteriology changes with recurrence—initial abscesses typically grow Staphylococcus, while recurrent abscesses show mixed flora requiring broader antibiotic coverage. 2

Antibiotic Selection

• Administer broad-spectrum antibiotics covering Staphylococcus aureus and oral flora during the perioperative period. 7
• Appropriate options include clindamycin (300-450 mg four times daily) or a cephalosporin plus metronidazole combination for broader coverage. 7
• Duration should be 5-10 days following definitive surgical excision. 8, 9

Special Anatomic Considerations

The inner breast location mentioned in your case is significant, as inferior breast and perianal/vulvar locations have higher recurrence rates even after wide excision. 1 This reinforces the need for complete excision of all involved ductal tissue rather than limited procedures.