Periareolar Abscess

Periareolar abscess is a collection of pus in the skin and superficial tissue at the margin of the areola, arising from infected Montgomery glands, hair follicles or skin breaks, and sometimes from a superficial branch of a milk duct. It occurs in lactating and non lactating women, and is more common with nipple piercing, shaving around the areola and skin conditions. It matters because it is painful, may recur, and is usually treated by simple drainage.

• Risk factors: nipple or areolar piercing, shaving or waxing, folliculitis, hidradenitis suppurativa, diabetes, smoking, obesity, previous abscess.
• Staphylococcus aureus is the commonest organism.
• Usually superficial and less deep than a subareolar abscess.

Women have a painful, red, tender swelling at the edge of the areola with a central pustule or point of fluctuance, with or without fever. The nipple and breast tissue behind are usually normal.

• Tender red lump at the areola margin, 1 to 3 cm.
• Pus discharge from a small opening.
• Differential diagnosis: subareolar abscess, periductal mastitis, infected sebaceous cyst, Montgomery gland cyst, furuncle, hidradenitis suppurativa, herpes simplex, eczema, lactational abscess, breast cancer.
• Complications: cellulitis, recurrent abscess, spread to deeper breast tissue, scarring, fistula, sepsis, chronic nipple pain.

The diagnosis is clinical, with ultrasound if the collection is deep or the diagnosis uncertain.

• Examination of the areola, nipple, breast and axilla; temperature.
• Ultrasound to show the depth and extent of the collection and any link to a duct.
• Pus culture and sensitivity (including methicillin-resistant Staphylococcus aureus); glucose.
• Biopsy of any mass that persists after healing.

The principle is simple drainage of pus with antibiotics when there is cellulitis, systemic illness or risk factors, and removal of the cause.

• Supportive: warm compress 3 to 4 times daily; keep the area clean and dry; remove nipple jewellery; stop shaving around the areola; dressing changes; paracetamol for pain; continue breastfeeding if lactating and the wound is away from the nipple.
• Pharmacological: lignocaine 1 percent infiltration, 3 to 10 mL (maximum 3 mg/kg, not above 200 mg), for drainage; flucloxacillin 500 mg oral 6-hourly for 7 days when there is cellulitis or fever; cefalexin 500 mg oral 6-hourly for 7 days as an alternative; penicillin allergy or methicillin-resistant Staphylococcus aureus: clindamycin 300 to 450 mg oral every 6 to 8 hours for 7 days; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days.
• Procedures: small incision and drainage under local anaesthesia with loose packing or a wick, removed after 24 to 48 hours; needle aspiration for small collections; excision of a sinus or cyst wall for recurrent lesions.
• Special groups: women with diabetes need insulin and a 10 day antibiotic course; women with hidradenitis suppurativa are referred for specialist care.
• Red flags: spreading redness, fever above 38.5 degrees Celsius, deep breast involvement, recurrent abscesses, a mass persisting after healing, pus from the nipple, systemic illness.
• Follow-up: wound review at 48 hours; review at 1 week; healing check at 4 weeks; ultrasound if swelling persists; surgical review after the second episode.