Definition and clinical significance

Breast dimpling refers to the puckering or retraction of the skin overlying the breast tissue. This physical finding results from abnormal attachment or tethering of the skin to underlying fibrotic or neoplastic tissue. Breast dimpling is a significant clinical sign as it often indicates an inflammatory or malignant process beneath the skin surface, most commonly breast carcinoma. Unlike benign breast lesions, which rarely cause skin retraction, breast dimpling usually represents an advanced or locally invasive disease stage. While predominantly observed in women over 40 years of age, dimpling can occasionally be seen in men and adolescents, usually related to trauma or benign pathology such as fat necrosis (1–3).

Pathophysiology

The mechanism of breast dimpling involves fibrosis or infiltration of Cooper’s ligaments and dermal attachments by tumor cells or inflammatory processes, causing localized skin retraction. Tumors located near the skin surface induce tethering, and the fibrotic reaction reduces skin elasticity, producing visible dimples, especially when the pectoralis muscles are tensed or the skin is gently pulled upward (4,5).

Clinical presentation

Patients with breast dimpling often first notice other signs such as a palpable lump, nipple retraction, or changes in breast contour before dimpling is apparent. However, thorough clinical breast examination, including inspection with arms raised and skin traction, can reveal early skin changes. Associated symptoms might include pain, tenderness, nipple discharge, erythema, or warmth depending on underlying etiology (6).

History and physical examination

A detailed history should explore risk factors for breast cancer, including age, family history (especially first-degree relatives with breast or ovarian cancer), reproductive history (nulliparity or late first full-term pregnancy), and lifestyle factors such as diet and hormone use (7,8). Inquiry about recent trauma, lactation status, signs of infection, or systemic symptoms (fever, malaise) is important.

Physical examination must be systematic:

• Inspect breasts in multiple positions: arms at sides, raised overhead, and leaning forward.

• Observe for asymmetry, skin changes (dimpling, erythema, peau d’orange), nipple abnormalities (retraction, inversion, discharge).

• Palpate for masses: note size, shape, consistency, mobility, and relation to skin or chest wall.

• Examine axillary and supraclavicular lymph nodes for enlargement (9).

Differential Diagnosis

Breast Cancer

Breast cancer is the most concerning cause of breast dimpling. The tumor is usually firm, irregular, fixed to skin or chest wall, and painless. Skin dimpling indicates local invasion or fibrosis and often coexists with nipple retraction, peau d’orange, or ulceration in advanced disease. Early detection improves prognosis; hence dimpling warrants urgent evaluation (1,3,10).

Breast abscess and mastitis

In lactating women, breast dimpling can be due to mastitis or abscess formation. Mastitis involves inflammation and infection leading to swelling, erythema, warmth, tenderness, and sometimes nipple cracks or purulent discharge. Chronic abscesses may cause fibrosis and tethering, producing dimpling. Systemic symptoms like fever and malaise are common. Prompt antibiotic therapy and drainage are essential (4,11).

Fat necrosis

Following trauma or surgery, fat necrosis can mimic malignancy clinically and radiologically. It presents as a firm, irregular lump with associated skin tethering and dimpling. Tenderness, bruising, and erythema may also be present. Biopsy is often required to exclude cancer (12).

Other benign conditions

Benign breast cysts or fibroadenomas typically do not cause dimpling. However, large lesions causing skin stretching or tethering can occasionally produce mild retraction (6).

Table 1: Medical causes of breast dimpling and associated clinical findings

Diagnostic Workup

• Imaging: Diagnostic mammography and breast ultrasound are first-line investigations to characterize masses, skin thickening, or architectural distortion. MRI may be indicated in ambiguous cases (10,13).

• Biopsy: Core needle biopsy or excisional biopsy is required for histopathological diagnosis.

• Laboratory tests: In mastitis or abscess, culture and sensitivity of purulent material guide antibiotic therapy (11).

Management

• Breast Cancer: Multimodal treatment including surgery, chemotherapy, radiation, and hormone therapy tailored to tumor stage and receptor status (10).

• Infectious Causes: Antibiotics, drainage of abscesses, and supportive care; breastfeeding should be continued or temporarily substituted with formula if necessary (4).

• Fat Necrosis: Conservative management if asymptomatic; surgical excision if diagnosis is uncertain or lesion enlarges (12).

Patient counseling and support

The presence of breast dimpling often causes psychological distress related to fears of cancer and body image. Sensitive communication, education on examination techniques, explanation of diagnostic steps, and reassurance are critical components of care (14). Patients should be taught breast self-examination and the importance of regular clinical screening (7).

Pediatric considerations

Breast cancer is exceedingly rare in children and adolescents; trauma or fat necrosis are more common causes of dimpling in this age group. Pediatric breast masses require careful evaluation but generally have a benign course (15).

References

1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin. 2009;59(4):225–49.

2. Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.

3. Gradishar WJ, Anderson BO, Abraham J, et al. Breast Cancer, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2020;18(4):452–78.

4. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 8th ed. Philadelphia: Elsevier; 2016.

5. Ahn S, Kim J, Lee J, Nam S, Kim H. Fat necrosis of the breast mimicking breast carcinoma: a clinical and radiological study. Ann Surg Treat Res. 2015;89(6):327–33.

6. Stuckey A, McGough C, Anderson P. Breast Cancer: Pathophysiology, Clinical Features and Diagnosis. Aust Fam Physician. 2017;46(4):153–7.

7. American Cancer Society. Breast Cancer Facts & Figures 2019-2020. Atlanta: American Cancer Society, Inc.; 2019.

8. Moyer VA. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;160(4):271–81.

9. McIntosh SA, Eisenberg E, Sadoughi B, et al. The clinical importance of nipple discharge. J Am Board Fam Med. 2021;34(1):74–82.

10. Zaha DC, Barboza MA, Goulart RA, Soares Junior JM. Imaging features of inflammatory breast cancer and mastitis: a diagnostic challenge. J Clin Imaging Sci. 2019;9:23.

11. Ogundipe OK, Ogunbiyi JO, Oluwasola AO, Oladele C. Mastitis in lactating women in Ibadan, Nigeria: aetiology and antibiotic susceptibility. Niger Postgrad Med J. 2010;17(3):170–4.

12. Rizzo M, Bussani R, Todaro F, et al. Clinical and pathological features of breast abscess: a review of 59 cases. Breast J. 2014;20(5):498–502.

13. King TA, Morrow M. Surgical considerations in breast cancer: recent progress and new questions. J Clin Oncol. 2015;33(33):3534–40.

14. Sauter ER, Ramos D, Fetterman B, et al. Breast cancer prevention and early detection: a review. Cancer Epidemiol Biomarkers Prev. 2017;26(7):923–35.

15. Ahn SH, Son BH, Kim SW, et al. Expression of estrogen and progesterone receptors in breast cancer and their clinical significance. J Korean Med Sci. 2010;25(4):524–31.