Nipple 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 Nipple 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 Speciality Delivery group meetings has focused on the referral
of women with nipple issues to secondary care services.

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. Eczema

• 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 exclude Paget’s Disease of the nipple.
• If there is doubt in the breast clinic as to the nature of a skin issue, a punch biopsy should be performed.

2. Benign Nipple Inversion

• Benign nipple inversion is common and often unilateral.
• Slit-like or reversible nipple inversion is due to normal elasticity of the milk ducts or benign duct ectasia. It does not require further investigation or referral to secondary care.
• Benign nipple inversion may be associated with apparent nipple discharge, either due to duct ectasia or retained shed skin cells. This does not need further investigation or specific management (see below).
• Surgical correction of benign nipple inversion is specifically not recommended under the Exceptional Aesthetic Referral Pathway as it frequently recurs.
• New persistent nipple inversion should prompt secondary care referral to exclude an underlying cancer.

3. Nipple Discharge

• Nipple discharge is usually innocent.
• Bilateral or multiple duct discharge is either physiological or due to innocent duct ectasia. Further investigation or referral to secondary care are not required.
• Discharge warranting referral and further investigation emerges from a single duct and is serous or bloodstained or bloodstained from multiple ducts. About 95% of such cases are innocent (usually due to intraduct papilloma or duct ectasia). Approximately 5% are caused by DCIS.
• 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.

4. Mammography

• Mammography is recommended as part of standard one stop triple assessment in those with single duct serous or bloodstained nipple discharge aged over 40. Ultrasound of ducts deep to nipple area should be performed in such cases if duct excision is not planned.

5. Surgical Management

• Duct excision should be considered for those with single duct, blood-stained or serous nipple discharge due to the low risk (~5%) of incidental DCIS.
• Duct excision may be considered for symptomatic relief of discharge that is frequent and troublesome.
• Decisions on whether a single duct (microdochectomy) or all ducts should be excised will vary from patient to patient depending on factors including age, plans for future breast feeding, confidence in sampling correct duct and likelihood of recurrence of discharge after microdochectomy for duct ectasia with increased risk to nipple blood supply with repeat surgery.
• Nipple eversion surgery is specifically not recommended in the Scottish Exceptional Aesthetic Referral Pathway.

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. Association of Breast Surgery. Guidelines for the investigation and management of spontaneous nipple discharge in the absence of a breast lump [Internet]. London: ABS; 2019 [cited 2026 May]. Available from: https://bobresource.com/wp-content/uploads/2023/05/ABS-nipple-discharge-v1.pdf 

3. Scottish Government. CMO(2019)05: Exceptional Referral Protocol (previously known as the Adult Exceptional Aesthetic Referral Protocol) [Internet]. Edinburgh: Scottish Government; 2019 [cited 2026 May]. Available from: https://www.publications.scot.nhs.uk/files/cmo-2019-05.pdf 

4. NHS Scotland. Exceptional (Aesthetic) Referrals Protocol – Local implementation guidance [Internet]. 2023–2026 [cited 2026 May]. Available from: https://www.rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/policies-and-protocols/exceptional-aesthetic-referrals-protocol/ 

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