Axillary Issues

Overview

The Modernising Patient Pathway Programme (MPPP) Symptomatic Breast Specialty Delivery Group (SDG) has been established to support and explore innovative approaches to the delivery of symptomatic breast services across NHS Scotland.

Through the development of Once for Scotland approaches to delivery of patient care, there is a strong focus on identifying opportunities to further develop clinical pathways. This aims to reduce unwarranted variation in the quality of care and to improve waiting times for non-urgent breast services. Specialty Delivery Groups play a key role in this work by engaging clinical leadership and fully utilising their roles across NHS Scotland.

The development of a Axillary Issues Pathway has been progressed through the MPPP SDG, reflecting a common theme identified during engagement with colleagues across NHS Scotland.

The recommendations outlined have not followed the standard SIGN development process and are instead based on available guidance and expert consensus. Peer review has also been undertaken to provide appropriate quality assurance.

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

Consensus

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

A consensus was formed around the principles that:

Patient Guidance

The Breast Services pathways for Scotland seek to promote equitable, safe, and timely access to assessment and care for all patients presenting with breast related symptoms, including breast pain, nipple discharge, axillary or skin lumps, and gynaecomastia. Pathway access and clinical decision‑making should be based on the presenting symptom, underlying breast tissue, and individual clinical risk, ensuring that no patient is unintentionally disadvantaged.

These symptomatic pathways apply to all patients, including trans and gender‑diverse individuals. Referral, investigation, and management should be guided by the nature of the presenting symptom, relevant anatomy, prior medical or surgical history (including any gender-affirming treatment), and clinical risk factors, rather than gender identity alone. The aim is to ensure that patients with breast symptoms are directed to the most appropriate diagnostic pathway without delay.

Patients who have residual breast tissue, regardless of gender identity, should be referred through standard symptomatic breast pathways when they present with breast symptoms. Those who have had chest or breast surgery may still require referral if symptoms arise in remaining breast tissue, the chest wall, axilla, or skin.

In light of the Supreme Court ruling on the definition of biological sex within the Equality Act 2010, services should recognise that biological sex may remain a relevant determinant for certain aspects of investigation, clinical management, or accommodation within breast services. Where this is the case, any alternative arrangements should be proportionate, clinically justified, and handled sensitively, ensuring patient dignity while maintaining safety and pathway clarity.

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.

5. Normal Structures

• Patients do sometimes complain of lumpy areas due to normal tendons and muscles, particularly in the upper inner arm. 
• Patients can be reassured.

1. Scottish Government. Scottish Referral Guidelines for Suspected Cancer [Internet]. Edinburgh: Scottish Government; 2025 [cited 2026 May]. Available from: https://www.gov.scot/publications/scottish-referral-guidelines-suspected-cancer-2025/ 

2. Remedy BNSSG Integrated Care Board (2025) Axillary masses (adult breast pathway). Available at: https://remedy.bnssg.icb.nhs.uk/adults/breast/axillary-masses/ 

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