Subareolar abscess, also called Zuska's disease for non pregnancy related cases, is a subcutaneous abscess of the breast tissue beneath the nipple. It is a frequently aseptic inflammation and has been associated with squamous metaplasia of lactiferous ducts. The term is usually understood to include breast abscesses located in the retroareolar region or the periareolar region but not those located in the periphery of the breast. Subareolar abscess can develop both during lactation or extrapuerperal, the abscess is often flaring up and down with repeated fistulation.
Pathophysiology 90% of cases are smokers, however only a very small fraction of smokers appear to develop this lesion. It has been speculated that either the direct toxic effect or hormonal changes related to smoking could cause squamous metaplasia of lactiferous ducts. It is not well established whether the lesion regresses after smoking cessation. Extrapuerperal cases are often associated with hyperprolactinemia or with thyroid problems. Also diabetes mellitus may be a contributing factor in nonpuerperal breast abscess.
Treatment Treatment is problematic unless an underlying endocrine disorder can be successfully diagnosed and treated. A study by Goepel and Panhke provided indications that the inflammation should be controlled by bromocriptine even in absence of hyperprolactinemia. Antibiotic treatment is administered for acute inflammation. However, this approach is rarely effective on its own, and the treatment of a subareolar abscess is primarily surgical. In cases of an acute abscess, incision and drainage are performed, followed by antibiotic therapy. In contrast to peripheral breast abscesses, which often resolve after antibiotic treatment and incision and drainage, subareolar breast abscesses tend to recur and are frequently accompanied by the formation of fistulas connecting the inflamed area to the skin surface. In many instances, particularly in patients with recurrent subareolar abscesses, excision of the affected lactiferous ducts is indicated, along with the removal of any chronic abscess or fistula. This procedure can be performed using either a radial or circumareolar incision. There is no universal agreement on what should be the standard way of treating the condition. In a recent review article, antibiotics treatment, ultrasound evaluation and, if fluid is present, ultrasound-guided fine needle aspiration of the abscess with an 18 gauge needle, under saline lavage until clear, has been suggested as initial line of treatment for breast abscess in puerperal and non-puerperal cases including central (subareolar) abscess (see breast abscess for details). Elsewhere, it has been stated that treatment of subareolar abscess is unlikely to work if it does not address the ducts as such. Duct resection has been traditionally used to treat the condition; the original Hadfield procedure has been improved many times but long-term success rate remains poor even for radical surgery. Petersen even suggests that damage caused by previous surgery is a frequent cause of subareolar abscesses. Goepel and Pahnke and other authors recommend performing surgeries only with concomitant bromocriptine treatment.
Squamous metaplasia of lactiferous ducts
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