Nipple inflammation: causes and treatment

"Nipple inflammation" is not a single diagnosis, but an umbrella term for a spectrum of conditions: from contact dermatitis and mechanical fissures to bacterial periductal inflammation, candidiasis-like dermatoses, viral lesions (herpes), and even an oncological mask – Paget's disease of the nipple. In nursing mothers, the inflammation is almost always associated with impaired milk drainage, nipple trauma, and microecological imbalance; in non-nursing mothers, dermatoses, duct ectasia, and periductal mastitis (Zuska's disease) are more common. Understanding the specific scenario determines treatment: where only corrected attachment and care are needed, where antibiotics are needed, and where urgent referral to an oncologist is needed. [1]

The modern concept of the "mastitis spectrum" (Academy of Breastfeeding Medicine, 2022) teaches us to view breast and nipple inflammation as a continuum, ranging from engorgement and microtrauma to subclinical/bacterial inflammation and abscess formation. This helps to intercept the problem early and avoid unnecessary antibiotics. The key is restoring effective milk flow and gentle nipple management; antibiotics and incisions should be reserved for compelling indications. [2]

A separate, important issue is periductal mastitis (Zuska's disease): chronic inflammation of the large ducts beneath the areola, closely associated with smoking, with recurrent fistulas at the areola. Simple courses of antibiotics often fail to resolve the problem; it has been proven that sustained remission is more often achieved after excision of the affected terminal ducts and smoking cessation. [3]

Finally, Paget's disease of the nipple is a rare but critical "mask" of chronic "eczematous" nipple in adults: a slow-healing "dermatitis" of the nipple/areola may be a superficial manifestation of breast cancer. Any chronic eczematous changes of the nipple in non-lactating women or outside the postpartum period require oncologic alertness and verification. [4]

Code according to ICD-10 and ICD-11

In ICD-10, inflammatory diseases of the mammary gland are coded in block N61 "Inflammatory diseases of the mammary gland." Within this block are N61.0 "Mastitis without abscess," N61.1 "Abscess of mammary gland and nipple," N61.2 "Granulomatous mastitis," with additional clarifications on sides and complications if necessary. This is a convenient "framework" for lactating and non-lactating patients; concomitant skin diagnoses (e.g., nipple dermatitis) can be coded in L-class blocks, and suspected Paget's disease - in oncological sections (C50.*). [5]

In ICD-11, inflammatory diseases of the breast are grouped into GB21 "Inflammatory Disorders of Breast" with post-coordination for lateralization and precise localization (including the extensions "XA5MC5 - nipple," "XA2JK3 - areola/ducts")—this allows for the description of "exactly where" and "on which side." Oncoclusters are used for Paget's disease and cancer, and nipple dermatitis is classified in skin disease blocks. This modular approach simplifies statistics and routing. [6]

Table 1. Examples of coding for "nipple/areola inflammation"

Clinical situation	ICD-10 (example)	ICD-11 (example)
Lactation mastitis without abscess	N61.0	GB21 (Inflammatory disorder) + XK9K/XK8G (side) + XA5MC5 (nipple)
Areola/nipple abscess	N61.1	GB21.0 (Breast abscess) + post-coordination for localization
Periductal mastitis (Zuska's disease)	N61.0/N61.1 (by phase)	GB21.Y "other inflammatory" + "location: ducts/areola"
Eczematous dermatitis of the nipple	L30.* + N61.0 (if secondary infection)	Dermatitis (L-class) + anatomical extension "nipple"
Suspected Paget's disease	C50.0 (nipple and areola cancer)	2C** (malignant breast tumor) + "areola/nipple"
[7]

Epidemiology

Symptoms of nipple inflammation in nursing mothers are one of the leading reasons for consultations during the first 6-12 weeks of lactation. Most episodes are "early" (associated with the establishment of breastfeeding) and respond well to adjustments in technique and regimens; a minority progress to bacterial mastitis and abscess. The updated ABM protocol emphasizes that a significant proportion of cases are resolved conservatively, without antibiotics, if milk drainage is restored promptly. [8]

Periductal mastitis is less common in non-lactating women but is prone to recurrence and fistulas. The most clear association is with smoking: tobacco smoke induces chronic duct inflammation, epithelial metaplasia, and a tendency toward obstruction. A systematic review emphasized that without smoking cessation and/or surgical excision of the terminal ducts, recurrence is highly likely. [9]

Eczematous lesions of the nipple have many forms, ranging from classic atopic/contact dermatitis to secondary bacterial infection. Herpetic nipple lesions in nursing mothers are a special case – a rare but clinically significant condition (blisters, erosions, severe pain). Breastfeeding from the affected breast should be avoided until healing due to the risk of transmitting the virus to the infant. [10]

Finally, Paget's disease of the nipple accounts for a fraction of a percent of all breast cancers, but is often diagnosed late because it masquerades as "chronic dermatitis." Any "persistent nipple eczema" in adults outside of lactation is a cause for oncological alertness and morphological verification. [11]

Reasons

In nursing mothers, the leading mechanisms are mechanical trauma to the nipple (shallow latch, inappropriate pump funnel), milk stagnation, and localized edema. Bacterial inflammation, often polymicrobial, may occur secondary to this. The underlying risk is not the microbes themselves, but rather disrupted milk flow and a damaged epidermal barrier. [12]

In non-lactating women, the causes shift to periductal inflammation (Zuska's disease, often in smokers), duct ectasia, contact/atopic dermatitis, and, less commonly, granulomatous mastitis ("idiopathic," sometimes associated with corynebacteria). Herpetic lesions are characterized by contact/autoinoculation; rapid differentiation is important because feeding tactics change. [13]

The issue of nipple candidiasis remains controversial: some studies find an association between Candida spp. and pain and cracking, while others question the "yeast" hypothesis as a universal explanation, pointing to overdiagnosis and misinterpretation of causes (mechanical trauma, dermatitis, bacterial inflammation). The conclusion from practice: clinical evaluation is critical, and antifungal agents are prescribed only according to strict indications. [14]

Risk factors

For lactating mothers: improper latch, pain, and refusal to latch on → engorgement; hyperlactation due to "overpumping" with a pump; an unsuitable pump funnel and excessive vacuum force; cracked/dry skin; stress, lack of sleep. Prevention begins in the first hours after birth and includes frequent latching, positioning correction, and a "gentle" pumping regimen. [15]

For non-nursing mothers: smoking (a key factor in Paget's disease), nipple piercing, tight/rubbing bras, contact allergens (creams, patches), underlying dermatoses (atopy, psoriasis), diabetes. With long-term eczematous changes in adults, an additional oncological risk factor is Paget's disease. [16]

Table 2. Main risk factors and intervention points

Group	Factors	What to fix
Nursing	Shallow latch, hyperlactation, cracks, pump at maximum	Latch training, funnel selection, on-demand, skin care
Non-nursing	Smoking, piercing, contact irritants, dermatoses	Smoking cessation, fistula repair, allergen elimination
General	Dry skin, tight underwear, injuries	Softening therapy, correct underwear
[17]

Pathogenesis

The basic mechanism in nursing mothers is a triad: milk stagnation → tissue swelling → nipple microtrauma. Swelling compresses the milk ducts, impairing milk flow, and damaged skin becomes an entry point for bacteria. Conservative therapy (frequent latching, warmth before/cold after, gentle drainage) breaks this vicious cycle. [18]

Periductal mastitis is a chronic inflammation of large ducts associated with metaplasia and obstruction; tobacco smoke and pyrolysis products exacerbate the microscopic inflammatory cascade, leading to relapses and fistulas. In this case, comprehensive "source" treatment—excision of the affected ducts—is the key to remission. [19]

In Paget's disease of the nipple, tumor cells from the ducts migrate into the epidermis of the nipple, forming a long-lasting "eczema" with scales/crusts. Any "persistent nipple eczema" in an adult should be considered a potential cancer until proven otherwise. [20]

Symptoms

General: pain, burning, hyperesthesia, redness, cracks, crusts; serous/purulent discharge is possible. In nursing mothers, signs of mastitis are added: a lump in the segment, a "flu-like" condition, subfebrile/fever. With an abscess - fluctuation, severe pain. [21]

Nipple herpes is a sudden, severe pain and clustered blisters/erosions on the nipple/areola, usually unilateral. Breastfeeding from the affected breast is contraindicated until the rash has completely healed; breastfeeding can be performed on the other breast if there is no rash. Antiviral therapy (acyclovir/valaciclovir) is compatible with lactation. [22]

Nipple eczema (contact/atopic) – itching, flaking, cracking, relief from mild topical steroids and elimination of irritants. However, unilateral, long-term "eczema" in adults outside of lactation requires the exclusion of Paget's disease. [23]

Forms and stages

It is practically convenient to divide: I) Non-inflammatory dermatoses (contact/atopic dermatitis, psoriasis), II) Trauma and "nipple wound" (crack, erosion), III) Infectious lesions (bacterial, viral, spore-yeast), IV) Periductive processes (Zuska's disease, duct ectasia), V) Oncological masks (Paget's disease). Within the lactating women, a gradation according to ABM is added: from engorgement/lactostasis to clinical mastitis and abscess. [24]

Table 3. "Map" of forms of nipple inflammation

Group	Key Features	First steps
Dermatoses	Itching, flaking, triggers (creams/patches)	Elimination + mild topical steroids
Trauma/crack	Pain with latch/pump, linear defect	Latch/funnel correction, wet healing
Bacterial	Local pain, pus, worsening within 24-48 hours	Antibiotics as indicated
Herpes	Blisters/erosions, severe pain	Antiviral, prohibition of breastfeeding with this breast
Zuska/ectasia	Relapses, fistula at the areola, smoking	Surgery + Smoking Cessation
Paget	Persistent nipple eczema in an adult	Biopsy, oncological route
[25]

Complications and consequences

Without correcting technique, breastfeeding mothers experience chronic pain, reduced feeding volume, and lactostasis leading to mastitis leading to abscess formation. In the case of herpes, there is a risk of transmission to the infant (neonatal herpes infection requires intensive treatment), so isolation of the affected breast is essential. [26]

In non-lactating women, the periductal process leads to recurrent fistulas, cosmetic defects, and repeated antibiotic courses without lasting effect. In the oncology field, the price of delay is the loss of an "early window" for diagnosing Paget's disease/underlying cancer. [27]

When to see a doctor

Immediate: high fever, flu-like condition + painful segment, suspected abscess (fluctuation), herpetic vesicles/erosions on the nipple (stop feeding on that breast), rapid skin growth/retraction. These are "48 hours or less" situations for changing tactics. [28]

Urgently planned: crack/pain that does not improve within 24-48 hours despite correct latch and frequent latching; recurrent periareolar inflammation in non-lactating women (suspected of Paget's disease); unilateral nipple eczema in an adult for more than 2-4 weeks - to exclude Paget's disease. [29]

Diagnostics

Clinical assessment is the basis: in nursing mothers, the mother-infant pair is examined, latch/positions are assessed, and the pump/funnel is inspected; in non-nursing mothers, smoking, piercings, and care products are clarified. In case of localized complications, a breast ultrasound is performed to search for an abscess (provides a picture of the cavity/fluctuation; allows for drainage under guidance). [30]

Cultures of the contents are useful in cases of pus/recurrence and failure of empirical therapy; in granulomatous mastitis, the possible role of corynebacteria is considered. In herpes, the diagnosis is clinical; PCR/smear confirmation can be used as indicated. [31]

If Paget's disease is suspected, dermatoscopy and targeted biopsy of the nipple/areola with immunohistochemistry are performed; in parallel, visualization of the mammary gland by age (mammography/ultrasound, MRI if necessary) to search for the underlying ductal process. [32]

Table 4. What, when and why to prescribe

Situation	Tool	Target
Pain + compaction, suspected abscess	Ultrasound + puncture/drainage	Diagnosis and treatment at the same time
Recurrent periareolar fistulas	Ultrasound/fistulography as indicated	Planning for duct excision
Nipple eczema in adults	Biopsy	Rule out Paget's disease
Herpetic picture	Clinic ± PCR	Confirmation/isolation of the affected breast
[33]

Differential diagnosis

Dermatitis vs. infection: Itching and relief from topical steroids/elimination of the irritant suggest dermatitis; pus and worsening with conservative measures suggest a bacterial infection. However, trauma and dermatitis often become secondarily infected; combined treatments are not uncommon. [34]

Yeast dermatitis: a controversial nosology; with a smooth, pink areola without plaque and with pain during latch, latch/trauma is most often the culprit. Antifungal agents are justified in cases of obvious signs of candidiasis (shine/maceration, plaque, positive smears in mother/child) and the ineffectiveness of corrective technique. [35]

Herpes vs. bacterial erosion: grouped blisters/erosions, burning pain, rapid onset – suggest herpes; feeding behavior is fundamentally different. Paget's vs. eczema: persistent unilateral "eczema" in adults – "until proven otherwise, it's Paget's" → biopsy. [36]

Treatment

1) Nursing: conservative “first echelon” (24-48 hours for mild/moderate course).

• Optimization of milk flow: frequent application on demand, warmth before/cold after, gentle massage “in the direction of flow”, in case of severe engorgement - gentle reverse pressure/short pumping “until softness”.
• Nipple wound healing: "wet" healing (hydrogels/soft balms), avoid alcohol/aggressive hygiene; latch/pump funnel correction, vacuum limitation.
• Pain relief/anti-inflammatory support: ibuprofen and compatible analgesics; continue feeding - this speeds recovery. [37]

2) Antibiotics - as indicated. If signs of a bacterial process are present (increasing erythema/pain, pus, fever, worsening after 24-48 hours of correct measures), systemic antibiotics are prescribed according to local protocols (covering staphylococci/streptococci; in case of relapses and fistulas, consider anaerobes). The course is usually 10-14 days to reduce recurrence. In case of an abscess - targeted drainage under ultrasound guidance + antibiotics. [38]

3) Herpetic lesion of the nipple. Breastfeeding is prohibited from the affected breast until complete epithelialization; breastfeeding is permitted from the healthy breast if there is no rash and any extrathoracic lesions are carefully covered. Acyclovir/valaciclovir (compatible with lactation) and topical care are prescribed. This reduces the risk of neonatal herpes infection. [39]

4) Periductal mastitis/Zuska's disease. In the acute phase, antibacterial therapy and drainage of the abscess are recommended; for recurrent forms, the "gold standard" is excision of the terminal ducts and smoking cessation (otherwise, relapse is highly likely). Surgical techniques vary, but the principle is to remove the source of obstruction/infection at the areola. [40]

5) "Candidiasis" - use cautiously and with specific care. Given the controversial nature of the diagnosis, empirical fluconazole is not prescribed "just in case." Indications: typical clinical presentation + confirmation/concomitant candidiasis in the mother/child + ineffective latch correction. When prescribing, simultaneously treat the child's oral cavity and sterilize nipple shields/bottles. [41]

6) Paget's disease. Oncological tactics: biopsy → staging → surgery/systemic therapy based on the molecular subtype and location of the underlying lesion (often ductal carcinoma). Delay due to "self-treatment of eczema" worsens outcomes. [42]

Table 5. Choice of tactics for nipple inflammation (brief algorithm)

Scenario	The first 24-48 hours	Escalation
Pain/fissure without systemic signs	Latch, drainage, moist healing, NSAIDs	If it gets worse → antibiotics/ultrasound
Local erythema + pus/fever	Antibiotics immediately, continue drainage	Ultrasound-guided abscess drainage
Herpes (vesicles/erosions)	Isolation of the affected breast, acyclovir	Resume feeding after healing
Relapse in a non-lactating woman (fistula)	Antibiotics/drainage	Ductectomy + smoking cessation
"Eczema" in an adult >2-4 weeks	Skin care	Biopsy to exclude Paget's disease
[43]

Prevention

For breastfeeding mothers, prevention involves maintaining milk flow hygiene: early initiation, frequent latching, deep latch training, proper pump selection, and avoiding "pumping for the sake of reserve." Cold after feeding reduces swelling and pain, decreasing the risk of cracks. Realistic expectations and access to a lactation consultant are important. [44]

Preventing infectious complications isn't about "preventative antibiotics," but about early technique adjustments and skin care. If you're prone to injury, use moist healing and limit aggressive hygiene (soap and alcohol dry out the skin and open the door to infection). [45]

For non-nursing women, the key is stopping smoking (significantly reduces the risk of recurrence of Zuska's disease), careful care after nipple piercing, eliminating contact irritants, and choosing the right underwear. Any prolonged eczematous changes in adults require timely biopsy to prevent cancer development. [46]

Table 6. Mini-checklist of prevention for home

Target	What to do daily
Reduce trauma	Learn and test the latch, change positions, and select the pump funnel
Reduce swelling	Heat before/cold after, gentle massage during application
Avoid hyperlactation	Express milk "as needed," not "just in case."
Skin care	Wet healing of cracks, minimum aggressive hygiene
Non-nursing	Quit smoking, avoid irritants, control dermatoses
[47]

Forecast

In most patients (whether breastfeeding or not), with early, correct management, symptoms resolve within a few days, and full recovery occurs within 1-2 weeks. The risk of relapse in breastfeeding women is reduced with a consistent feeding rhythm and proper latch. [48]

Recurrent periareolar lesions in smokers require surgical correction of the source (duct excision) – this offers the best chance of lasting remission. In Paget's disease, the prognosis is determined by the stage of the underlying cancer: early detection significantly improves outcomes. [49]

FAQ

Is this definitely "nipple thrush"?
Not always. "Nipple candidiasis" is a controversial diagnosis; more often, the cause is trauma, dermatitis, or bacterial infection. Antifungal medications are not indicated "just in case," but rather based on clinical evidence and confirmation. [50]

Can I continue breastfeeding if I have an inflammation?
In the vast majority of cases, yes, it's part of the treatment. The exception is herpetic nipple lesions: don't feed from the affected breast until it heals; the other breast is allowed if there's no rash. [51]

When are antibiotics needed?
If, after 24-48 hours of corrective measures, the condition worsens/no improvement occurs, there is pus/fever, or signs of an abscess. The course is usually 10-14 days; in case of an abscess, drainage is performed under ultrasound guidance. [52]

How are recurrent areola fistulas treated in non-lactating women?
Most often, excision of the terminal ducts and smoking cessation are required—this is the only way to achieve lasting remission. [53]

Is nipple eczema in adults dangerous?
If it's unilateral and doesn't resolve within 2-4 weeks, yes, it's a red flag for Paget's disease: a biopsy and oncologic evaluation are needed. [54]

Table 7. "Red flags" - do not delay in contacting

Symptom	Why is it dangerous?	What to do
Fluctuating/throbbing pain, temperature	Abscess	Ultrasound + drainage + antibiotics
Blisters/erosions on the nipple, severe pain	Herpes: Risks for Children	Do not breastfeed, acyclovir
Unilateral "eczema" in an adult >2-4 weeks	Paget's disease	Biopsy, oncological route
Recurrent periareolar "abscess" in non-lactating women	Zuska's disease	Surgery + Smoking Cessation
[55]