Breast Skin Problems

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 Breast Skin Problems 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 Breast Specialty Delivery group meetings has focused on the referral of women with breast skin 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. Imaging of Breast Tissue

• Specific breast imaging is not required outwith screening if examination of breast tissue is normal on examination.

2. Skin Itch, Scaling and Redness (often affecting areola)

• Eczema of the breast is common and often presents with itch, redness, skin thickening and scaling of the skin, often affecting the areola. The skin can become raw and weep. This should be distinguished from discharge from the milk ducts of the nipple.
• It can be managed as eczema elsewhere on the body.
• If cases fail to settle with local steroid or similar changes are present affecting the nipple itself, patients should be referred to the breast service to exclude Paget’s Disease of the nipple.
• If there is doubt in the breast clinic regarding the nature of a skin condition, a punch biopsy should be performed.

3. Redness of Skin

• Patchy and variable erythema of the skin of the breast is common and usually entirely innocent.
• Reassurance is usually all that is required.
• Inflammatory breast cancer occurs when lymphatic channels with the breast are obstructed. This results in oedema and erythema of the breast often with a palpable mass and/or palpable lymph nodes. It is rare but concern should prompt urgent referral to the breast service.

4. Skin Cysts

• Skin cysts affecting the breast area are common, particularly affecting the underside of the breast and axilla.
• 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 under the breast or the axilla (with the groins often also affected) is due to hidradenitis suppurativa. Surgical management of this condition is discouraged and referral through dermatology pathways may be considered.

5. Skin Cancer

• Skin cancer can affect the breast and suspected cases can be referred through dermatology pathways.

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. NHS Scotland (Right Decisions). Breast skin problems [Internet]. 2023–2026 [cited 2026 May]. Available from: https://www.rightdecisions.scot.nhs.uk/breast-pathways/breast-skin-problems/ 

3. Referral Management Service (Cornwall NHS). Breast/nipple skin changes guideline [Internet]. [cited 2026 May]. Available from: https://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/breast_guidelines/breast_skin_changes 

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Centre for Sustainable Delivery

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