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Redness, sores, eczema, crusting, and cracking of the breast most commonly occur due to skin irritation, infections, allergic reactions, and hormonal changes. These findings may appear individually or together, and the underlying cause must be evaluated correctly.
Redness and skin sensitivity in the breast usually develop as a result of fungal or bacterial infections, sweating, and irritation caused by friction. They are more common especially during breastfeeding, in patients with diabetes, and in individuals with weakened immune systems, and they may spread.
Eczema and crusting on the breast are most commonly associated with allergic dermatitis, atopic eczema, or exposure to products containing chemicals. Contact factors such as detergent, soap, perfume, or bra fabric may disrupt the skin barrier, causing itching and scaling.
Causes of sores and cracking on the breast include dryness, constant scratching, improper hygiene practices, and, rarely, inflammatory breast diseases. Lesions that do not heal for a long time or are accompanied by discharge or changes in shape must be medically evaluated.
Why do redness and changes occur on the breast skin?
Breast tissue and the skin covering it behave somewhat differently from the skin on other parts of the body. This is not a static structure; it is a constantly changing dynamic organ in which hormones act as the conductor of an orchestra. In particular, the nipple and the dark-colored ring around it (areola) form a bridge between the outside world and the milk ducts inside the breast. This area is rich in nerve endings and is extremely sensitive both to touch and hormonal fluctuations.
The reactions of your breast skin also change during different periods of your life. From puberty to menopause, the hormones estrogen and progesterone may increase or decrease the blood flow and sensitivity of the skin. For example, immediately before your menstrual periods, you may feel that the skin of your breasts is tighter and more sensitive along with a sense of fullness. However, the period that challenges the breast skin the most is undoubtedly breastfeeding. Mechanical trauma, a moist environment, and the active functioning of the milk ducts make the skin vulnerable to infections and irritation. While redness on the breast skin may sometimes indicate a disease limited to the skin itself, at other times it may be a cry for help from the tissue underneath.
How can it be understood whether it is simple eczema or an allergy?
In a large proportion of my patients who come to the outpatient clinic with the complaint, “I have persistent itching and redness on my breast,” the problem is actually a dermatological reaction, meaning one specific to the skin. Since the breast skin is delicate, it may react more severely here to substances that other parts of your body can tolerate. We call this “contact dermatitis.” In other words, when your skin comes into contact with a substance it does not tolerate, it raises a flag of rebellion. This condition usually manifests as sharply demarcated redness, sometimes tiny fluid-filled blisters, and unbearable itching.
The most common factors that trigger such reactions are:
- Newly introduced body shampoos
- Detergent residues left on clothing
- Fabric softeners
- Perfumed body lotions
- Bras made of synthetic fabrics
- Lace underwear
- Cosmetic creams applied to the nipple
In addition to this list, especially in women with large breasts or during hot weather, we frequently encounter rash-like conditions in the folds under the breasts. These areas, which remain moist and poorly ventilated, unfortunately provide an ideal environment for fungal infections. In this condition, which we call “intertrigo,” bright red lesions, sometimes covered with white plaques and accompanied by a burning sensation, form beneath the breast. In addition, conditions such as psoriasis or seborrheic dermatitis triggered by stress may also cause scaling on the breast skin. In such cases, avoiding the irritating substance and using simple creams usually resolves the problem. However, the danger here is that constant scratching disrupts the integrity of the skin, allowing bacteria to enter through cracks and cause more serious infections.
What are the symptoms of breast infection and mastitis?
Mastitis, which means inflammation of the breast tissue, is one of women’s greatest fears. Although it is generally associated with breastfeeding mothers, it can also occur in women who have never given birth or who completed breastfeeding long ago. However, the development of these two conditions is quite different.
Mastitis during breastfeeding (lactational mastitis) usually appears during the first weeks when the baby begins to suckle. Tiny visible or invisible cracks that form on the nipple act like a highway for bacteria living on the skin, usually staphylococci, to enter the milk ducts. If the milk ducts are not emptied completely and milk accumulates inside, these bacteria multiply rapidly. The body reacts strongly to this invasion.
The most common complaints described by my patients during this infection are:
- Sudden onset of breast swelling
- Severe pain that increases with touch
- Localized increase in skin temperature
- Widespread redness
- High fever
- Episodes of chills
- Weakness
Mastitis occurring in women who are not breastfeeding is a more persistent and complicated process. Unfortunately, one of the main culprits here is smoking. Toxins in cigarette smoke damage the milk ducts immediately behind the nipple, causing inflammation and blockage of the ducts. This condition, which we call “periductal mastitis,” may recur frequently, and its treatment may take longer than that of lactational mastitis.
Is surgery necessary when a breast abscess develops?
If mastitis is not recognized in time and treated with strong antibiotics, or if the body cannot cope with the bacteria, it builds a wall to limit the infection and accumulates pus inside. This is what we call a breast abscess. Abscesses are among the conditions in which redness and throbbing pain in the breast are most severe.
In the past, medical practice was dominated by the idea that “if there is an abscess, it must be cut open.” In other words, the abscess was surgically opened and drained. However, today, as general surgeons, we are much more cautious about making an incision in the breast. This is because every incision leaves an aesthetic scar and increases the risk of forming persistently draining channels (fistulas) that are difficult to heal.
Our treatment strategy has changed with the modern approach. We now use ultrasound like an eye to locate the abscess with millimetric precision and drain it with the help of a thick needle/syringe (aspiration). This procedure is much more comfortable for the patient and accelerates the healing process. We prefer surgical drainage only in very advanced cases that are extremely large, cannot be drained with a needle, or have caused tissue loss (necrosis). The question breastfeeding mothers ask most often is, “Should I stop breastfeeding?” Our answer is clear: No. Unless there is a condition that could harm the baby, emptying the milk is one of the most effective methods for resolving the infection.
Could non-healing sores be Idiopathic Granulomatous Mastitis?
Here is one of the diseases that challenges general surgeons the most and exhausts patients both physically and psychologically: Idiopathic Granulomatous Mastitis (IGM). Although its name is somewhat long and complicated, you can also remember this disease as the “Cancer Mimicker.” This is because the findings it creates are so similar to breast cancer that even an experienced surgeon cannot distinguish between the two without performing a biopsy.
This disease usually targets young women of childbearing age, between 30 and 40 years old, who have previously given birth. Although the cause is unknown, it is thought to be an excessive and incorrect immune response of the body against its own breast tissue or a substance in the milk ducts. It is not a microbial condition, meaning it is not contagious, but the damage it causes in the breast resembles an infection.
Typical symptoms observed in patients with IGM are:
- A hard and irregular mass in the breast
- Redness of the skin
- Nipple retraction
- Thinning and perforation of the skin
- Inflammatory discharge
- Recurrent sores
The most frustrating aspect of this disease is that it never responds to standard antibiotics. The patient uses boxes of antibiotics, but the mass does not shrink and the redness does not disappear. The diagnosis can only be made by examining a sample taken from the suspicious tissue (biopsy) in pathology and identifying special inflammatory cells called “granulomas.” Its treatment is like running a marathon; months of corticosteroid treatment or medications that suppress the immune system may be required. Unfortunately, the disease tends to recur, meaning it may reappear after it is thought to have healed. Therefore, our patients diagnosed with this condition need to stay in close communication with their surgeons and be patient.
Why does inflammatory breast cancer cause redness?
Now we come to a somewhat more serious subject, an area where red flags are raised. Not every redness in the breast is harmless. A special and aggressive type called “Inflammatory Breast Cancer” (IBC) disguises itself as inflammation. This type of cancer accounts for a small percentage of breast cancers but is one of the most insidious.
While a hard mass can be felt in classic breast cancer, the situation is different in the inflammatory type. Cancer cells block the lymphatic channels beneath the breast skin. This blockage prevents the skin from draining lymphatic fluid and causes severe edema in the breast. As a result, the breast swells, becomes red, and feels warm. It appears as though there is a serious infection inside.
The most critical signs suggesting inflammatory breast cancer are:
- Redness covering one-third of the breast
- Orange peel appearance
- A feeling of heaviness in the breast
- Inward retraction of the nipple
- Swelling in the armpit
- Sudden increase in breast size
The “orange peel” (peau d’orange) appearance here is very characteristic. The pores on the skin become prominent, the skin thickens, and it develops a rough texture just like the surface of an orange. The most vital point of distinction is this: If you are taking antibiotics for a diagnosis of mastitis (infection) and there is no significant improvement in your complaints within 10-14 days, or if the redness is increasing, this is not normal. In such a situation, inflammatory breast cancer must be investigated without delay by performing a biopsy. Early suspicion saves lives.
Is nipple eczema a sign of Paget’s disease?
Our patients who come with complaints of itching, scaling, and crusting on the nipple usually begin by saying, “Doctor, I have eczema on my nipple, and it just won’t go away.” Yes, this appearance resembles eczema. However, in breast surgery, we have a golden rule: Eczema-like lesions on the nipple are considered suspicious until proven otherwise. This is because a rare type of cancer called “Paget’s Disease of the Breast” appears in this disguise.
Paget’s disease is the presence of cancer cells in the skin of the nipple, and in almost all cases, there is an underlying breast cancer, usually milk duct cancer, in the invisible part of the iceberg deep within the breast. Patients generally apply corticosteroid creams purchased from a pharmacy or already available at home. Interestingly, these creams temporarily suppress the symptoms. The itching decreases and the redness fades. This period of “false recovery” is the most dangerous stage because it causes the patient to postpone visiting a doctor for months. Meanwhile, the underlying disease continues to progress.
You should consult your doctor if the following symptoms are present:
- Rashes occurring on only one breast
- Scaling on the nipple
- Yellowish discharge
- Crusting
- Bleeding
- A non-healing sore
- Flattening of the nipple
- Burning sensation
A biopsy is essential for any nipple sore that lasts longer than two weeks and does not improve despite treatment. Do not be frightened by the word biopsy; this procedure is generally a very small and painless procedure performed in an outpatient setting after numbing the skin.
When are nipple cracks and discharge dangerous?
Nipple discharge is one of the most common reasons women visit our outpatient clinics. Since the breast is a milk-producing gland, discharge is not actually surprising. Most discharges are caused by hormonal factors, medications, or benign processes. As surgeons, we divide discharges into those that are “concerning” and those that should be “monitored.”
Discharges that should be monitored, meaning those that are generally physiological, are those that appear when you squeeze the nipple, may come from both breasts, and are yellow, green, gray, or milky white in color. These are usually related to stress, antidepressant use, or widening of the milk ducts.
However, the characteristics of discharges that carry a surgical risk and definitely require further investigation are:
- Occurring spontaneously without squeezing the nipple
- Originating from only one breast
- Coming from a single point on the nipple
- Being clear like water
- Being bloody or pinkish in color
- Soaking the bra at night
Bloody discharge is particularly alarming. The most common cause is benign small growths called “papillomas” that develop inside the milk duct. However, there is also a 10-15% chance that they may be an early sign of breast cancer. Therefore, in patients with bloody or watery discharge, the duct from which the discharge originates must be imaged or the fluid must be examined. Any nipple discharge observed in men is much more serious than in women and must be investigated for cancer.
Which methods do we use to make a diagnosis?
When you come to us with a problem involving the breast skin, visual examination alone is not enough. We need to use the technological eyes provided by modern medicine. Our goal during this process is to understand whether the problem is limited only to the skin or whether it has a deeper underlying source.
The first step is usually radiological imaging. In every woman over the age of 40, mammography is our indispensable map. We can clearly see skin thickening, edema, or calcifications within the breast (microcalcifications) on mammography. Ultrasonography, especially in young patients and women with dense breast tissue, is like an extension of the surgeon’s hands. Ultrasound allows us to determine where an abscess is located and whether the inside of a mass is filled with fluid or solid tissue.
In more complicated cases, especially when Paget’s disease or Inflammatory Breast Cancer is suspected, Breast MRI (Magnetic Resonance Imaging) comes into play. MRI captures the most sensitive image of the breast and reveals hidden lesions that may be missed by mammography or ultrasound. It is our most powerful tool for determining the extent of the disease.
However, radiology tells us, “There is something suspicious here,” while pathology gives it a name. In other words, a tissue sample is essential for a definitive diagnosis.
The biopsy methods we use during the diagnostic process are:
- Fine-needle aspiration
- Core needle (Tru-cut) biopsy
- Punch biopsy
- Vacuum-assisted biopsy
- Surgical biopsy
For changes in the breast skin, we generally use the method called a “punch biopsy.” With a tiny instrument measuring 3-4 millimeters, we take a full-thickness sample of the skin and send it to pathology. If there is a mass inside the breast, then a core needle biopsy called “Tru-cut” is the gold standard. Please do not believe the myth that cancer spreads if it is touched by a knife or pierced by a needle. A biopsy does not spread the disease; on the contrary, it enables the correct treatment to be planned.
How should the treatment process and approach be?
Once the diagnosis is made, treatment is shaped entirely according to the name and stage of the disease. If the condition is simple dermatitis or a fungal infection, the process is completed within a short time with suitable creams and hygiene recommendations. In cases of mastitis or abscess, the patient is relieved with the correct antibiotic choice and, if necessary, drainage of the abscess.
However, if the diagnosis is malignancy, meaning cancer, treatment becomes a team effort. This team includes a surgeon, medical oncologist, radiation oncologist, radiologist, and pathologist. In aggressive conditions such as inflammatory breast cancer, the “medication first” approach, meaning neoadjuvant chemotherapy, is generally adopted. The goal is to eliminate cancer cells from the body through systemic treatment and reduce the edema in the breast. Surgery is usually considered after this treatment.
In Paget’s disease or other types of breast cancer, surgical options are evaluated. Depending on the size and location of the tumor and the patient’s preference, two main approaches may be followed:
- Breast-conserving surgery
- Mastectomy (removal of the breast)
Today, our fundamental philosophy in breast surgery is to ensure oncological safety, meaning freedom from cancer, while preserving the woman’s bodily integrity and quality of life at the highest possible level. In breast-conserving surgery, only the diseased area is removed with a safe margin, followed by radiotherapy (radiation treatment). If the entire breast needs to be removed, the breast structure can be reconstructed through aesthetic repair procedures performed either at the same time or later.
Frequently asked questions
Prof. Dr. Ebru Ayvazoğlu Soy is a physician known for her academic background and surgical experience in the field of general surgery. After graduating from TED Ankara College in 1998, she completed her medical education at Hacettepe University Faculty of Medicine in 2005. She completed her residency training in the Department of General Surgery at Başkent University Faculty of Medicine in 2012, obtained the title of Associate Professor in 2019, and became a Professor in 2024. She currently serves as a faculty member in the Department of General Surgery at Ankara Medipol University Faculty of Medicine. With nearly 100 publications in international indexed journals and numerous scientific presentations, Prof. Dr. Ayvazoğlu Soy is a member of the International College of Surgeons, The Transplantation Society, Turkish Surgical Association and the Ankara Surgical Association. In addition to her academic position at Ankara Medipol University, she also sees patients in her private clinic in Çankaya, specializing in general surgery, breast surgery, and endocrine surgery.
