Reasoning GP · Algorithm · 1-page summary
Nipple problems
For: adults (women and men) with nipple discharge, retraction, skin change or nipple pain in primary care. Not for: children; lactational mastitis (use the mastitis and breast abscess protocol); a breast lump or pain without a nipple change follows NICE NG12 (block 1).
Core rule: ask first “one nipple or both?” One-sided discharge, retraction or skin change needs breast referral; a persistent one-sided nipple rash is Paget’s disease until proven otherwise — never a prolonged steroid trial.
0Stop — call 999 now — pituitary emergency or sepsis
- Suspected pituitary disease with sudden severe headache and visual loss or reduced consciousness (possible apoplexy) → 999. New visual or field loss, double vision, severe headache or vomiting → Same-day emergency department, not the breast unit.
- Breast infection with sepsis high-risk features (NICE NG253) → 999. A stable abscess or prolactinoma does not need 999 (block 2).
1Triage — NICE NG12 (updated April 2026)
| Finding | Action |
|---|---|
| One nipple, 50+ | Discharge, retraction or other change of concern → Suspected cancer referral |
| One nipple, under 50 | Bloodstained or single-duct discharge, new retraction → Urgent breast clinic, local pathway |
| Any age | Unilateral nipple eczema not responding to treatment, or recent distortion → Urgent breast referral (50+: suspected cancer referral, NG12) |
| Skin, any age | Change suggestive of cancer → consider Suspected cancer referral |
| Lump | Unexplained, 30+ (men too); man 50+, firm subareolar → Suspected cancer referral |
| Both nipples | Expressed, multi-duct, nothing else → no cancer referral |
2Screen — one row is enough
- Ulcerated, bleeding or eroded nipple, or rash + lump → Urgent breast referral; no topical trial.
- Periareolar swelling with fluctuance or unwell → Same-day breast assessment; otherwise same or next working day.
- Suspected prolactinoma, stable → Urgent endocrinology.
- Persistent or recurrent non-lactational mastitis (especially over 40) or bilateral acquired retraction → breast assessment to exclude malignancy.
3Assess
☐ Both breasts, nipple, areola, axillae and supraclavicular nodes ☐ Discharge: spontaneous or expressed, one or both sides, single or multiple ducts, colour ☐ Prolactin-raising medicines; smoking ☐ Galactorrhoea: pregnancy test, rested prolactin (repeat a modest rise; macroprolactin if persistent), TFTs, renal ± liver function, visual fields
Do not: repeatedly express the nipple, image before referral, or request pituitary MRI.
4Classify — only if the screen is negative
- Physiological — bilateral, milky, expressed only, multiple ducts, normal prolactin → reassure. Galactorrhoea (not pregnant or breastfeeding) → drugs (commonest), hypothyroidism, renal, prolactinoma.
- Duct ectasia / periductal mastitis — bilateral pasty multi-duct discharge, smoker → treat; refer if one-sided persistence, lump, retraction, skin change or postmenopausal.
- Contact dermatitis — bilateral, areola more than nipple. Breastfeeding pain — latch first; Raynaud’s (white–blue–red after feeds) is often mislabelled as thrush.
- Uncertain or one-sided → breast referral; never assume benign without specialist review.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Periductal mastitis, no abscess: local guideline (currently co-amoxiclav 500/125 mg three times daily, 10–14 days; penicillin allergy: clarithromycin + metronidazole) → review at 48–72 h and by 5–7 days; stop smoking.
- Contact dermatitis: remove the allergen; hydrocortisone 1% twice daily for 2–4 weeks if inflamed — not for unilateral, erosive or bleeding change.
- Drug-induced galactorrhoea: medication review; never stop or switch an antipsychotic without the psychiatrist. Hypothyroid → levothyroxine; macroprolactinaemia → reassure.
- Nipple Raynaud’s: warm compress after feeds; avoid cold and smoking. Off-label nifedipine only once confirmed.
6Refer routinely · review
- Endocrinology: persistent unexplained raised prolactin on repeat, hypogonadism, markedly raised level, or the drug cannot be stopped. Cabergoline is specialist-led only.
- Recurrent periductal mastitis → breast unit (duct excision). Persistent dermatitis → patch testing. Latch problems → lactation consultant (IBCLC), health visitor.
7Never reassure by — or do
- A one-sided nipple rash that “looks like eczema”, or a repeated steroid trial.
- A normal breast examination: it does not exclude Paget’s or an intraductal lesion.
- A presumed papilloma or duct ectasia for bloodstained one-sided discharge.
- Antibiotic response alone in persistent or recurrent mastitis over 40.
- Screening status: symptoms need diagnostic assessment whatever the screening record.
- Diagnosing nipple thrush from burning pain or a shiny nipple alone.
8Safety-net — say it, then document it
999 “Call 999 for a sudden severe headache with loss of vision or drowsiness, or an infected breast with feeling very unwell.” Same day “Contact us or the breast unit the same day if the swelling grows quickly, becomes soft or you get a fever; go to A&E today with any new problem with your sight or a severe headache.”
Return if discharge becomes bloody or one-sided, a lump appears, a nipple turns in or a rash does not settle. Awaiting referral: check it was received; worsening → breast unit same day.
✓Safe to manage in primary care only if — all five, documented
No block 0–2 feature; no NG12 or one-sided criterion met
Both breasts, axillae and nodes examined; one or both sides recorded
Pregnancy, medicines and smoking checked; prolactin and TFTs if milky
Cause named; review booked (48–72 h if mastitis)
Safety-net given and documented
Summary of the full Reasoning GP nipple problems algorithm, which holds the detail, prolactin interpretation, specialist treatment and evidence. Sources: NICE NG12 (updated April 2026); BASO breast discharge guidelines; NICE CG164; MHRA ergot-derived dopamine agonists; local antimicrobial guidelines. Clinical reference — follow local breast and endocrine pathways and check doses: NICE/SPC, BNF.