Nipple retraction is the inward displacement of the nipple below the level of the surrounding breast tissue. It usually indicates an acquired pathologic process involving scarring or shortening of subareolar structures, rather than a congenital anomaly. Retraction differs from nipple inversion, which is often benign and present since birth.

Pathophysiology

Nipple retraction results from fibrosis and contracture within the breast parenchyma or ducts.

• Inflammatory or infectious processes: Chronic mastitis, abscess, or duct ectasia cause periductal scarring, pulling the nipple inward.

• Malignant processes: Carcinomas or Paget’s disease induce stromal fibrosis and tethering of Cooper’s ligaments or lactiferous ducts, leading to progressive flattening and retraction.

• Post-surgical changes: Scar formation following breast surgery may shorten subcutaneous tissue planes.

Fibrotic changes around major ducts shorten their length, altering nipple projection and producing deviation, flattening, and, eventually, retraction.

History and Physical Examination

History

• Onset and progression of retraction

• Associated symptoms: pruritus, burning, discoloration, discharge, breast pain, swelling, warmth, or new masses

• Past breast infections or trauma

• History of breast surgery or biopsy

• Risk factors for breast cancer: family history, prior breast malignancy, nulliparity, late first pregnancy, early menarche, late menopause

Physical Examination

1. Inspection

   • Assess both breasts with the patient sitting: arms relaxed, raised overhead, hands pressing hips, leaning forward.

   • Note nipple flattening, deviation, erosion, or scaling.

   • Look for breast asymmetry, dimpling, peau d’orange, erythema, or ulceration.

2. Palpation

   • In supine position, palpate the subareolar region and entire breast for discrete masses or induration.

   • Attempt gentle eversion of the nipple by squeezing the areola.

   • Mold breast tissue over a lump or lift toward the clavicle to accentuate retraction.

   • Palpate axillary lymph nodes.

Emergent considerations

• Sudden onset of nipple retraction, especially with bloody discharge or a firm mass, may indicate malignancy and warrants urgent evaluation.

• Retraction associated with fever, warmth, and tenderness suggests an abscess or severe mastitis needing immediate treatment.

Medical causes

Differentiating Nipple Retraction from Inversion

Other causes

• Post-surgical scarring or radiation fibrosis

• Rarely, traumatic injury causing fibrosis

Special considerations

• Always evaluate retraction in postmenopausal women as potentially malignant until proven otherwise.

• Prepare patients for diagnostic tests: mammography, ultrasound, cytology of discharge (if present), or core biopsy.

Patient counseling

• Teach monthly breast self-examination and stress prompt reporting of new nipple or breast changes.

• Explain the likely cause (benign vs. malignant) and discuss the proposed diagnostic plan.

• Reassure patients with congenital inversion that the condition is generally harmless.

Pediatric pointers

Nipple retraction does not occur in prepubescent females; new retraction in adolescents requires prompt evaluation for infection or mass.

References

1. Aliotta HM, Schaeffer NJ. Breast conditions. In: Schuiling KD, Likis FE, editors. Women’s Gynecologic Health. Burlington, MA: Jones & Bartlett Learning; 2013. p. 377–401.

2. Dixon JM, Mansel RE. ABC of breast diseases: symptoms assessment. BMJ. 1994;309(6956):722–6.

3. Cardenosa G. Breast Imaging Companion. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

4. Eberl MM, Phillips RL. Evaluation of nipple abnormalities. Am Fam Physician. 2004;70(9):1731–8.