What is the appropriate evaluation and management for a female patient of reproductive age with a papule on the left nipple and white discharge upon squeezing?

Management of Nipple Papule with White Discharge

This presentation is most consistent with a blocked Montgomery gland or small epidermal inclusion cyst, not true pathologic nipple discharge, and requires only conservative management with observation—no imaging is indicated. 1

Key Diagnostic Distinction

The critical feature here is that discharge originates from a discrete papule on the nipple surface, not from the lactiferous ducts within the nipple itself. 1 This fundamentally differentiates it from true nipple discharge requiring evaluation:

• True pathologic discharge originates from ductal orifices within the nipple, is typically spontaneous, unilateral, from a single duct, and serous or bloody 2, 3
• Your patient's presentation (papule expressing white material when squeezed) represents a benign dermal/glandular finding 1

Recommended Management Approach

Conservative observation is appropriate: 1

• Stop all manipulation and squeezing of the papule to prevent inflammation and secondary infection 1
• Apply warm compresses if discomfort develops 1
• The lesion will typically resolve spontaneously once manipulation ceases 1

What NOT to Do

Do not order mammography or ultrasound for this presentation—expressible material from a surface papule does not constitute true nipple discharge and does not warrant breast imaging. 1, 3

When to Escalate Evaluation

Formal imaging evaluation becomes necessary only if: 1, 3

• True spontaneous ductal discharge develops (fluid coming from the nipple itself, not the papule)
• A breast mass is palpated
• Discharge characteristics change to serous or bloody 3
• Discharge becomes unilateral and single-duct 3

If true pathologic discharge develops, then age-appropriate imaging is warranted (mammography/ultrasound for age ≥40 years, ultrasound alone for age <40 years). 1, 3

Clinical Pitfall to Avoid

The most common error is misidentifying this benign surface lesion as pathologic nipple discharge and ordering unnecessary imaging. 1 Remember that physiologic discharge (bilateral, multiple ducts, white/green/yellow, provoked only) also requires no imaging beyond routine screening if up to date. 2 However, this patient doesn't even have physiologic discharge—she has a blocked gland on the nipple surface.

Up to 50% of reproductive-age women can express fluid from their breasts, and most nipple discharge is benign. 4 The key is distinguishing surface lesions from true ductal pathology, which carries a 3-29% malignancy risk when pathologic features are present. 2