What is the best course of action for a 13-year-old male patient presenting with a 1 cm painful mass behind the left areola, which is palpable and located below the surface of the skin?

Management of Subareolar Mass in 13-Year-Old Male

This is almost certainly physiologic gynecomastia, which is extremely common in early adolescence and requires only reassurance and clinical observation—no imaging or biopsy is needed unless there are atypical features.

Initial Clinical Assessment

This presentation is classic for pubertal gynecomastia, which occurs in up to 65% of adolescent males and typically presents as:

• Unilateral or bilateral subareolar disc-like tissue 1
• Tender to palpation 1
• 1-2 cm in diameter 1
• Onset during Tanner stages 3-4 (ages 13-14) 1

The appropriate first step is clinical observation with reassurance, as the vast majority of cases resolve spontaneously within 1-2 years 1.

When Imaging Is NOT Indicated

For typical pubertal gynecomastia in males under 30 years:

• No ultrasound is needed for classic presentation 2, 1
• No mammography should be performed in this age group 2
• No biopsy is warranted for benign-appearing masses 2, 1

The cancer risk in this demographic is extraordinarily low—only 0.3% of patients younger than 25 years with probably benign features are subsequently diagnosed with malignancy 2.

When to Consider Ultrasound

Ultrasound should be obtained ONLY if 2, 1:

• The mass is hard, fixed, or irregular (not the soft, mobile disc described here)
• Rapid growth occurs over weeks
• Skin changes, dimpling, or nipple retraction develop
• Bloody nipple discharge is present
• The mass persists beyond 2 years or increases significantly in size

Management Algorithm

For this patient with typical features 1:

1. Reassure the patient and family that this is normal pubertal development
2. Advise against repeated self-examination or manipulation of the breast tissue, as this increases anxiety and tenderness 1
3. Schedule clinical follow-up in 6 months to document stability or resolution 1
4. Instruct to report immediately if new symptoms develop: spontaneous nipple discharge, rapid growth, skin changes, or new masses 1

Important Caveats

• If ultrasound is performed despite typical features and shows probably benign findings (BI-RADS 3), short-interval ultrasound follow-up every 6 months for 1-2 years is appropriate rather than biopsy 1
• Clinical-radiologic discordance mandates further evaluation: if clinical examination is highly suspicious but imaging is negative, tissue sampling may still be warranted 3
• The presence of pain actually supports a benign diagnosis in this age group, as malignancy is typically painless 1

Most cases resolve completely within 18-24 months without any intervention, making watchful waiting the evidence-based standard of care 1.