Nipple changes are common breast symptoms. Suspicious changes described below should be referred as a USC.
The majority of nipple issues are innocent and most can be managed without referral to secondary care.
USC Referral should be made for:
- Nipple discharge that is serosanguinous (clear yellow liquid with or without red blood staining)
- New, unilateral, and non-reversible nipple retraction
- Unilateral nipple eczema that is unresponsive to a two-week treatment with moderately potent topical steroids*
* In the experience of EBU Paget’s starts on the tip of the nipple and spreads out. Changes that are limited to the areola only are unlikely to be Paget’s.
(Details of other indications for Breast USC referral can be found under pages for Skin Changes, Breast Lumps, Breast Axillary Symptoms and Breast Abscess)
The Modernising Patient Pathways Programme summarises best practice for managing other Nipple Problems.
TF, EC, LP & JB FEB 26
Who to refer
Urgent Suspicion of Cancer Referral
- Nipple discharge that is serosanguinous (clear yellow liquid with or without red blood staining)
- New, unilateral, and non-reversible nipple retraction
- Unilateral nipple eczema that is unresponsive to a two-week treatment with moderately potent topical steroids*
* In the experience of EBU Paget’s starts on the tip of the nipple and spreads out. Changes that are limited to the areola only are unlikely to be Paget’s.
Routine Referral
- Persistent unilateral spontaneous troublesome discharge e.g. sufficient to stain outer clothes
Who not to refer
- Transient nipple discharge which is not bloodstained (check Prolactin levels when bilateral discharge present)
- Longstanding nipple retraction
- Reversible or intermittent nipple retraction
How to refer
Edinburgh, Midlothian, and East Lothian Patients
- Please refer via SCI Gateway to WGH
Western General Hospital >> General Surgery – Breast >> LI Breast – Urgent
OR
Western General Hospital >> General Surgery – Breast >> LI Breast – Non Urgent
West Lothian Patients
- Please refer via SCI Gateway to SJH
St John’s Hospital >> General Surgery – Breast >> LI Breast – Urgent
OR
St John’s Hospital >> General Surgery – Breast >> LI Breast – Non Urgent
Guidance on managing other Nipple symptoms is summarised in the MPPP linked to below.
The same information is available on the RDS:
- If the discharge is profuse and milky then check prolactin level before referring. A prolactin level of > 1000mU/L is significant. Please see Endocrinology guidance.
- If apparently benign discharge is very troublesome, surgical duct excision is considered but does result in a numb nipple and will not permit subsequent breast feeding.
- Modernising Patient Pathways Programme: Nipple Problems
- Nipple Problems on RDS
- HRT: further information on the known increased risk of BC with HRT and its persistence after stopping MHRA
- Breast Cancer at MacMillan
- Breast Cancer at Cancer Research UK
- Breast Cancer at Breast Cancer Now
- Breast Cancer section of Scottish Referral Guidelines for Suspected Cancer on RDS
