Treating breast abscesses

How is a breast abscess treated?

It’s important to remove the pus from a breast abscess. If it is not removed, it may remain in the breast and produce a lot of pain. Eventually, it will break through the skin. This fixes the abscess but may damage skin and prolong healing. Most abscesses can be drained by a health-care provider using a needle in a process called needle aspiration. If the abscess is large or if repeated aspirations don’t work, surgery may be needed. A cut is made into the pus pocket and the wound is left open, allowing the pus to drain, sometimes with the help of a small tube placed in the abscess. After the surgery, drainage slowly stops and the breast heals. Abscess treatment also includes continuing to remove milk from the breast if possible, antibiotics to limit the spread of bacteria, and medication to ease the pain.

A) Describing the treatment of breast abscesses

This breast abscess was not drained in time. The pus broke through the skin, resulting in a wound that took six weeks to heal.

A breast abscess is caused by a bacterial infection and consists of a collection of pusa yellow-white, creamy liquid, surrounded by swollen, inflamed breast tissue. Pus can also be bloody.

Please work with your health-care providers if you have developed a breast abscess.

1) Draining the pus

An abscess will not heal until the pus has drained however, it can take up to ten days for the pus to form and collect in the centre (pus pocket) of the abscess. This can be called ripening. Pus may start to form in very small pockets and draining them is difficult and generally not helpful. Within a few days, they usually join to make a larger pocket that can be drained.

Once the pus pocket has formed and is ready to be drained, the centre of the abscess may feel a little softer than the area around it (fluctuant). Ripening can also be confirmed with an ultrasound examination.

Once ripe, the pus should be removed (drained) by a health-care provider. If it is not drained, the pus will remain in the breast, causing pain and swelling, until it breaks through the skin. This fixes the abscess, but mothers may lose some skin and it will take a while to heal. This also increases risk of developing a fistula, a permanent passage between the area of the abscess and the outside. A fistula can leak milk.

2) Antibiotics

Treatment for an abscess usually includes antibiotics (Russell 2019). The same antibiotics used to treat mastitis are also used to treat breast abscesses. Nearly all antibiotics are compatible (pose little or no risk to the baby) with breastfeeding .

3) Breastfeeding

Mothers should continue to breastfeed on the normal breast.They are generally encouraged to continue breastfeeding on the affected breast if possible, and as long as the baby is not in direct contact with pus or infected tissue.  

If breastfeeding is too painful or they are separated from their babies, mothers can temporarily express. They must eusure that they do so effectively. The milk can be given to the baby as long as it has not touched pus or infected tissue.

4) Other tools

Mothers who have a breast abscess:

  • Can use the general care recommendations for the treatment of mastitis.
  • Can use anti-inflammatory medication for pain and fever (Montgomery et al. 2012).
  • Should rest and care for themselves.
  • Should expect to feel better within a few days of the abscess being drained.
  • Will have a breast lump that can take up to one month to clear after the pus has been removed.
  • May be left with a small 1 centimeter (1/2 inch) non-tender lump at the site of the abscess for months.

B) Draining the pus: needle aspiration versus incision and drainage

An abscess has pulled the nipple in and the breast is no longer making milk. The abscess was drained with a needle and settled. The puncture hole is seen at 9 o’clock.

Until recently, mothers with breast abscesses were given general anesthesia and routinely treated with aggressive breast surgery. The breast was cut open and the wound was allowed to drain (incision and drainage). Sometimes, strips of clean cloth (packing) were put into the breast to keep the wound open and draining.

It has since been shown that surgery is not necessary for most mothers with a breast abscess (Amir 2014). Some mothers with a severe abscess may need surgery, but most abscesses respond well to being drained with a needle (needle aspiration(Colin 2019)

One study (Christensen 2005) reported that 86 of 89 patients with a breast abscess needed needle aspiration only once. One patient needed it again and two patients needed surgery. Our clinic has had a similar experience; it is uncommon that mothers need incision and drainage.

Compared to incision and drainage, needle aspiration has several major advantages. It:

  • Is less traumatic for the mother emotionally and physically.
  • Does not require packing or wound care after surgery.
  • Avoids:
    • Hospitalization.
    • General anesthetic.
  • Causes virtually no damage to milk tissue and ducts.
  • Makes continuing to breastfeed easier and more likely (Saharan 2018).
  • May prevent a decrease in milk supply with the next baby.

C) Needle aspiration

The appearance of pus removed from a breast abscess with a needle.

Draining the pus is done with a needle (Kataria 2013; Lee 2011; Saharan 2018; Ulitzsch 2004). The skin to be pierced can be injected with medication to stop sensation (freezing) beforehand. This is not always helpful. Depending on the state of the skin over the abscess, the freezing can hurt as much as the aspiration.

Sometimes the pus pocket is easy to feel and relatively small. Your regular health-care provider may feel confident in aspirating the abscess. Alternatively, a radiologist or other trained provider can use ultrasound to guide the needle into the pus pocket. This is more accurate.

Using ultrasound is especially important if the abscess is more complicated and:

  • Has multiple pockets.
  • Is deep in the breast.
  • Is difficult to feel.
  • Is large.
  • Did not respond to previous needle aspiration.
  • May be caused by breast cancer.

After the pus pocket is emptied, it may refill with small amounts of breast milk and occasionally blood. The body then fills the pocket with healing tissues.

Occasionally, needle aspiration may need to be repeated.

D) Using a drain

If the pus pocket is larger, a tube (drain) may have to be placed in the abscess to allow the pus to leak out over a few days. If the wound cannot drain, the abscess may not clear (Colin 2019).

If the mother is undergoing needle aspiration, this is best done by a radiologist using ultrasound to guide the placement of the drain (Falco 2016).

If the mother is having surgery, the surgeon will place the drain.

Drains may have a suction device attached to help empty the pus pocket.

E) Surgery

Surgery may be needed if (Eryilmaz 2005; Giess 2014; Lam 2014):

  • The pus pocket is more than 5 cm (2 in) wide.
  • Pus is present in several areas throughout the breast.
  • The mother is extremely sick.
  • Repeated needle aspiration has not worked.

After freezing the overlying skin, a small cut is make into the pus pocket. The wound is left open, allowing the pus to drain out.

For severe infections or persistent abscesses, a larger cut may be needed. This may require a general anesthetic.

After surgery, the wound is left open, the drainage slowly stops, and the breast heals. Drain tubes are often helpful.

Mothers who have surgery, especially breast surgery, need additional practical and emotional support to help look after themselves and their baby.

F) Antibiotics

Mothers who are developing an abscess will be given an antibiotic by their health-care providers.

If an abscess is forming, it is rare that an antibiotic will stop it. This is because antibiotics work by travelling through blood vessels to get to the bacteria and then killing them. However, there are no blood vessels in a pus pocket, so the bacteria are protected. This is why abscesses nearly always need to be drained.

Antibiotics can limit the spread of bacteria into the rest of the breast and into the body. They work better once the abscess is drained.

A sample of the pus drained from the abscess is sent to a laboratory to identify the bacteria causing the infection. This helps health-care providers ensure mothers are on the right antibiotic. Once the test results are back, your health-care provider will advise you to continue with your current antibiotic or change to another one.

G) Healing after pus removal

Once the pus is removed, mothers will quickly feel better.

However, the part of the breast around the pus pocket is often inflamed and swollen, causing a lump. It is often a lot larger than the pus pocket. Such lumps can take up to four weeks to shrink to near normal size. We expect to see the lump shrink by at least 1/3 every 10 days.

During this time, mothers will still feel a lump and may worry that there is still pus in the breast. However, the pus is gone and the inflammation just needs more time to settle. All is well if there is a steady decrease in the:

  • Size of the breast lump.
  • Redness over the lump.
  • Amount of pain.

Mothers can mark the edge of the lump with a pen and measure and record the size to ensure the lump is shrinking steadily. Mothers can follow the redness using pictures. 

It is normal for a small 1 cm (1/2 in) lump to remain at the site of the abscess for months after the infection is gone.

H) Fistulas

Very rarely, a mother can develop a fistula which is a tract, or passage, from the inside of the breast through a hole in the skin. These can develop after (Alipour 2020; Larson 2016):

  • Surgery for an abscess.
  • An abscess that breaks open on its own.
  • Other types of breast surgery such as a large biopsy.

The fistula will leak milk. Most heal with time as breast tissue is very active and good at healing itself (Dominici 2010). Occasionally, a fistula does not go away until the mother stops breastfeeding (Larsen 2016; Lim 2018).

They rarely persist once breastfeeding has stopped. If they do, they can be repaired surgically.

References

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