How should a sore nipple in an adult be evaluated and managed?

Evaluation and Management of Sore Nipple in Adults

A sore nipple in an adult requires immediate differentiation between dermatologic conditions (eczema, irritant dermatitis, infection) and pathologic nipple discharge with underlying breast pathology—the latter carrying up to 21% malignancy risk and demanding urgent imaging evaluation. 1, 2

Initial Clinical Assessment

Determine if nipple discharge is present:

• If discharge is present, characterize it as physiologic versus pathologic 2, 3:

  • Pathologic features (any single feature warrants full evaluation): unilateral, spontaneous, single duct, bloody or serous appearance 2, 3
  • Physiologic features: bilateral, multiple ducts, white/green/yellow/clear color, only with provocation 4, 2, 3

• If no discharge, focus on dermatologic causes 5, 6:

  • Assess for eczema (atopic, irritant, allergic contact dermatitis) 5
  • Evaluate for infection (candidiasis, bacterial) 5, 6
  • Consider psoriasis, though less common 5

Critical Red Flags Requiring Urgent Evaluation

The following features mandate immediate imaging and possible biopsy to exclude malignancy:

• Unilateral persistent nipple lesion with erythema, erosion, or crusting—must exclude Paget's disease (found in >80% of cases with underlying breast cancer) 7
• Pathologic nipple discharge with palpable mass (61.5% malignancy risk vs 6.1% without mass) 2
• Male patient with nipple symptoms (23-57% malignancy rate) 2, 3
• Age >60 years with pathologic discharge (32% malignancy rate) 2
• Acquired nipple inversion 8, 7

Imaging Algorithm for Pathologic Discharge or Suspicious Lesions

For patients ≥40 years:

• Start with diagnostic mammography or digital breast tomosynthesis (DBT) plus ultrasound 1, 2, 3
• Sensitivity 15-68% for mammography, 63-100% for ultrasound in detecting intraductal lesions 1, 2

For patients 30-39 years:

• Either mammography/DBT or ultrasound as initial study, with the other as complementary 1, 2, 3

For patients <30 years:

• Ultrasound as initial examination 3
• Add mammography only if ultrasound shows suspicious findings 3

If initial imaging is negative but pathologic discharge persists:

• Consider breast MRI (sensitivity 86-100% for detecting causes of pathologic discharge) 1, 2
• MRI particularly useful when mammography and ultrasound are negative 1

Management of Dermatologic Causes

For eczematous/inflammatory nipple conditions:

• First-line treatment: topical corticosteroids or calcineurin inhibitors (both safe during lactation) 5
• Identify and eliminate provoking factors: repetitive friction, chemical irritants, allergens 5
• Intensive moisturization with emollient wash products 5
• Warm water or black tea compresses for symptom relief 5

Common pitfall: Persistent unilateral nipple eczema that fails to respond to standard treatment within 2-3 weeks requires biopsy to exclude Paget's disease 7

When to Obtain Tissue Diagnosis

Image-guided core needle biopsy (preferred over FNA) is indicated for:

• Any BI-RADS category 4 or 5 lesion identified on imaging 1, 3
• Persistent unilateral nipple skin changes despite dermatologic treatment 7
• Suspicious intraductal lesions detected on ultrasound or MRI 1

Surgical duct excision is reserved for:

• Persistent pathologic discharge with negative imaging studies 1, 3
• Not indicated for physiologic discharge or routine dermatologic conditions 4, 3

Management Based on Discharge Characteristics

Physiologic discharge (bilateral, non-spontaneous, milky/green/yellow):

• No imaging needed if screening mammography is current 1, 4, 2
• Patient education: stop breast compression/manipulation 3
• Instruct patient to report any change to spontaneous, unilateral, or bloody discharge 4, 3

Pathologic discharge:

• Proceed with age-appropriate imaging algorithm as outlined above 1, 2
• Overall cancer risk 5-21%, with 10% at age 40 and 32% after age 60 1, 2

Special Populations

Lactating women:

• Topical corticosteroids and calcineurin inhibitors are safe 5
• Adjust latch/positioning during breastfeeding 5
• Consider nipple protection devices 5
• Ductography is contraindicated during active lactation 1

Male patients:

• Any nipple discharge in males warrants full imaging evaluation (57% malignancy rate in one study) 4, 2
• Ultrasound equally useful for lesion identification and biopsy guidance 1

Transgender patients on estradiol:

• Clear bilateral discharge requiring manual expression is physiologic 3
• No imaging needed unless discharge becomes spontaneous, unilateral, or bloody 3

Key Clinical Pearls

• Never dismiss persistent unilateral nipple changes as simple dermatitis—always consider Paget's disease 7
• Ultrasound and mammography are unreliable in predicting histologic diagnosis; tissue diagnosis is essential for image-detected lesions 1
• Most pathologic discharge is due to benign intraductal papilloma (35-48%), but 5-21% is malignant 2
• If dermatologic treatment fails within 2-3 weeks or symptoms worsen, refer for dermatology evaluation and consider biopsy 9, 7