Axillary issues

Background

The Modernising Patient Pathway Programme’s (MPPP) Symptomatic Breast Speciality Delivery Group has been established to support and look at new innovative ways to develop delivering Symptomatic Breast services across NHS Scotland.

Through development of Once for Scotland approaches for delivery of care, focus is being placed on looking at opportunities to develop clinical pathways to reduce unwarranted variation in delivery of quality healthcare and to sustainably improve waiting times for non-urgent care within breast services. Speciality Delivery Groups have been established to engage and fully utilise the role of clinical leadership across NHS Scotland.

Development of the Axillary Issues Pathway has been progressed through the Symptomatic Breast Specialty Delivery Group as it was a common theme identified during meetings held with colleagues across NHS Scotland.

The recommendations have not followed the standard process used by the Scottish Intercollegiate Guidelines Network (SIGN) but are based on available guidance and expert opinion, with peer review to provide quality assurance.

This guidance will be reviewed and updated as new evidence emerges.

Consensus

A common theme during the Breast Speciality Delivery group meetings has focused on the referral of women with axillary issues to secondary care services.

A consensus was formed around the principles that: Many axillary issues are innocent and can be managed without referral to secondary care

Pathway recommendations

1. Lymph nodes

Those with suspicion of one or more persistent axillary lymph nodes should be referred to secondary care. Haematological referral guidance suggests nodes above 2cm persisting for 6 weeks or increasing in size.
Consider other causes – eczema, rheumatoid arthritis, Human Immunodeficiency Virus (HIV).

2. Skin cysts

Skin cysts affecting the axillary area are common and usually do not require referral to secondary care.
Patients should be encouraged to stop smoking and lose weight.
Acute infection should be treated with appropriate antibiotics.
Significant abscesses may be referred to secondary care.
Discharging abscesses can be managed with dressings and often do not require referral.
Persistent troublesome individual lesions may be referred to secondary care for consideration of elective excision.
A constellation of lesions in the axilla (with the groins and underside of breasts often also affected) may be due to Hidradenitis Suppurativa (HS).
Medical management is usually the first line treatment of HS, with surgical management limited to selected cases.

3. Accessory axillary breast tissue

Accessory axillary breast tissue is common and usually does not require referral to secondary care.
This produces a soft bulge in the axilla without much to feel.
It is often asymmetrical.
Patients can be reassured.
Surgical treatment is discouraged in most cases.

4. Pain

Pain felt in the axilla is usually arising from the muscles in the chest wall area.
Patients can be reassured. Advice can be given to modify activity using the arm and shoulder, use simple analgesia or topical nonsteroidal anti-inflammatory drugs (NSAIDs).
Imaging is not required.