Breast cellulitis and other skin disorders of the breast
- J Michael Dixon, MD
J Michael Dixon, MD
- Professor of Surgery and Consultant Surgeon
- Edinburgh University
- Larry M Baddour, MD, FIDSA
Larry M Baddour, MD, FIDSA
- Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Cellulitis is an uncommon infection in the breast and can be difficult to distinguish from inflammatory breast cancer or benign erythematous conditions of the breast. Pain is a prominent feature of breast cellulitis and is associated with erythema, swelling, and warmth. Inflammatory conditions of the breast not related to cellulitis are reviewed elsewhere. (See "Nonlactational mastitis".)
Cellulitis and erythema of the breast is an uncommon presentation for women seeking medical care for a breast related-problem. For example, a prospective study of 3762 consecutive female patients evaluated in a dedicated breast center found that only 22 women (0.6 percent) presented with erythema of the breast during a 14-month interval, and of those 22, only 2 patients (9 percent) had cellulitis . In comparison, breast cellulitis occurs in approximately 1 to 8 percent of patients managed by breast conservation treatment (partial mastectomy and radiation therapy) [2-7].
Risk factors — Independent risk factors for breast cellulitis include [1-5,7-9]:
- Lactation (see "Lactational mastitis")
- Breast surgery within previous 30 days (surgical site infection) (see "Epidemiology of surgical site infection in adults")
- Prior breast cellulitis or infection
- Trauma (eg, bites, nipple piercing, tattoos)
- Infected skin lesions (eg, eczema, dryness, dermatitis)
- Breast conservation treatment for breast cancer (partial mastectomy and radiation therapy)
Beta-hemolytic streptococcus is an important cause of breast cellulitis [3,9,10]. A case-control study conducted in three metropolitan areas in the United States demonstrated that breast cancer was a risk factor for the development of group B streptococcal infection . Group B beta-hemolytic streptococci have a proclivity to produce soft-tissue infections in the setting of venous and/or lymphatic compromise . Staphylococcus aureus, including methicillin-resistant S. aureus, can also be an important pathogen. (See "Cellulitis and erysipelas" and "Group B streptococcal infections in nonpregnant adults".)
- Froman J, Landercasper J, Ellis R, et al. Red breast as a presenting complaint at a breast center: an institutional review. Surgery 2011; 149:813.
- Hughes LL, Styblo TM, Thoms WW, et al. Cellulitis of the breast as a complication of breast-conserving surgery and irradiation. Am J Clin Oncol 1997; 20:338.
- Mertz KR, Baddour LM, Bell JL, Gwin JL. Breast cellulitis following breast conservation therapy: a novel complication of medical progress. Clin Infect Dis 1998; 26:481.
- Indelicato DJ, Grobmyer SR, Newlin H, et al. Delayed breast cellulitis: an evolving complication of breast conservation. Int J Radiat Oncol Biol Phys 2006; 66:1339.
- Brewer VH, Hahn KA, Rohrbach BW, et al. Risk factor analysis for breast cellulitis complicating breast conservation therapy. Clin Infect Dis 2000; 31:654.
- Zippel D, Siegelmann-Danieli N, Ayalon S, et al. Delayed breast cellulitis following breast conserving operation. Eur J Surg Oncol 2003; 29:327.
- Baddour LM. Breast cellulitis complicating breast conservation therapy. J Intern Med 1999; 245:5.
- Miller SR, Mondry T, Reed JS, et al. Delayed cellulitis associated with conservative therapy for breast cancer. J Surg Oncol 1998; 67:242.
- Rescigno J, McCormick B, Brown AE, Myskowski PL. Breast cellulitis after conservative surgery and radiotherapy. Int J Radiat Oncol Biol Phys 1994; 29:163.
- Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med 1992; 93:543.
- Jackson LA, Hilsdon R, Farley MM, et al. Risk factors for group B streptococcal disease in adults. Ann Intern Med 1995; 123:415.
- Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis. Association with venous and lymphatic compromise. Am J Med 1985; 79:155.
- Peltecu G. Images in clinical medicine. Cellulitis after treatment for breast cancer. N Engl J Med 2007; 357:488.
- Staren ED, Klepac S, Smith AP, et al. The dilemma of delayed cellulitis after breast conservation therapy. Arch Surg 1996; 131:651.
- Peters F, Petersen EE, Kirkpatrick CJ. Isolated erythema (cellulitis) of the breast. Breast 2002; 11:484.
- Rahmouni A, Chosidow O, Mathieu D, et al. MR imaging in acute infectious cellulitis. Radiology 1994; 192:493.
- Chapter 23: Bacterial and rickettsial infections. Cellulitis. In: Weedon's Skin Pathology, 3rd, Weedon D. (Ed), Churchill Livingstone Elsevier, Philadelphia 2010. p.552.
- Dixon JM. Breast infection. In: ABC of Breast Diseases, Dixon JM (Ed), Blackwell Publishing, Oxford 2006. p.19.
- Foxman B, D'Arcy H, Gillespie B, et al. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol 2002; 155:103.
- Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol 2007; 109:479.
- Stafford I, Hernandez J, Laibl V, et al. Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization. Obstet Gynecol 2008; 112:533.
- Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database Syst Rev 2009; :CD005458.
- Hale TW, Berens PD. Clinical Therapy in Breastfeeding Patients, 2nd ed, Pharmasoft, Amarillo 2002.
- Vitug AF, Newman LA. Complications in breast surgery. Surg Clin North Am 2007; 87:431.
- Throckmorton AD, Boughey JC, Boostrom SY, et al. Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients. Ann Surg Oncol 2009; 16:2464.
- McNeely ML, Binkley JM, Pusic AL, et al. A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues. Cancer 2012; 118:2226.
- Milgrom S, Higgins SA. Management of cellulitis associated with treatment of breast cancer. J Support Oncol 2009; 7:174.
- Catania S, Zurrida S, Veronesi P, et al. Mondor's disease and breast cancer. Cancer 1992; 69:2267.
- Shetty MK, Watson AB. Mondor's disease of the breast: sonographic and mammographic findings. AJR Am J Roentgenol 2001; 177:893.
- Dixon JM. Breast abscess. Br J Hosp Med (Lond) 2007; 68:315.
- King R, Duncan L, Shupp DL, Googe PB. Postsurgical dermal lymphedema clinically mimicking inflammatory breast carcinoma. Arch Dermatol 2001; 137:969.
- Browse NL, Stewart G. Lymphoedema: pathophysiology and classification. J Cardiovasc Surg (Torino) 1985; 26:91.
- Marcks P. Lymphedema. Pathogenesis, prevention, and treatment. Cancer Pract 1997; 5:32.
- Clark CJ, Wechter D. Morphea of the breast--an uncommon cause of breast erythema. Am J Surg 2010; 200:173.
- Walsh N, Rheaume D, Barnes P, et al. Postirradiation morphea: an underrecognized complication of treatment for breast cancer. Hum Pathol 2008; 39:1680.
- Schaffer JV, Carroll C, Dvoretsky I, et al. Postirradiation morphea of the breast presentation of two cases and review of the literature. Dermatology 2000; 200:67.
- Dubner S, Bovi J, White J, Susnik B. Postirradiation morphea in a breast cancer patient. Breast J 2006; 12:173.
- Risk factors
- CLINICAL FEATURES
- Patient presentation
- Imaging studies
- - Mammogram
- - Ultrasound
- - Magnetic resonance imaging
- Laboratory findings
- - Laboratory tests
- - Blood cultures
- - Skin aspirate culture
- DIAGNOSTIC EVALUATION
- DIFFERENTIAL DIAGNOSIS
- Benign etiologies
- - Mondor's disease
- - Abscess
- - Postoperative dermal lymphedema
- - Morphea
- - Dermatologic disorders
- Malignant etiologies
- - Inflammatory breast cancer
- - Paget's disease
- Post-radiation treatment etiologies
- - Radiation induced dermatitis
- - Radiation induced fibrosis
- Guiding principles
- Recurrent cellulitis
- SUMMARY AND RECOMMENDATIONS