Nipple changes color/retracts/shrunk — What happens? Visual Guide
- ป้าหมอนุช
- 4 hours ago
- 10 min read
Nipple changes are divided into two main types — congenital (present at birth) and acquired (recently developed). Congenital nipple inversion, which has been present since childhood or adolescence, is usually harmless and occurs in 10-20% of women. However, 🚨 acquired nipple inversion — a nipple that has recently become inverted, retracted, or tilted to one side in women over 30-40 years old — is a sign that requires investigation as it could indicate breast cancer, Paget's Disease, or duct ectasia. A rash/sore on the nipple that does not heal within two weeks requires a skin punch biopsy to rule out Paget's Disease.
How common are nipple changes?
Changes in the nipples are a common problem that women notice — it's important to differentiate between congenital (born/harmless) and acquired (recently born/requires examination).
Important information:
Congenital nipple inversion — occurs in 10-20% of women · harmless.
Acquired Nipple Inversion — Significantly Increased Risk of Cancer · All cases require evaluation.
Paget's Disease — A rare form of breast cancer, found in 1-3% of all breast cancers. It involves changes in the nipple.
80-90% of Paget's Disease cases also include DCIS, or invasive breast cancer.
Acquired nipple inversion in women over 40 years old has the highest risk of cancer and requires urgent examination.
Congenital vs. Acquired Nipple Inversion — How to Differentiate Them
The most important difference in evaluating inverted nipples.
💚 Congenital Nipple Inversion (Congenital — Harmless)
It has been present since adolescence (puberty) or even earlier.
Mostly on both sides.
This is caused by short milk ducts or connective tissue pulling the nipple inward.
Some can be extracted when stimulated (Grade 1-2).
Constant, unchanged.
No lumps, no fluid, no skin changes.
🚨 Acquired Nipple Inversion (Recently occurred — requires testing)
It only starts to occur in adults (usually after the age of 30-40).
Mostly unilateral.
Nipples that were previously normal can change over a period of weeks to months.
Difficult to remove, stuck deep inside (Grade 3)
It may be accompanied by lumps, lymphatic fluid, or skin changes.
The nipple is angled toward the cancerous lump.
Important rule: Recently changed nipples (one side only) in women over 30 years old must be evaluated within 1 week — do not wait.
Han's Classification — Severity Levels of Nipple Inversion
A standardization system used for congenital nipple inversion to plan treatment.
Grade 1: Mild Inversion
Slightly inverted nipples
It can be easily removed and temporarily left in place.
Normal milk ducts
Connective tissue changes little.
Most mothers are able to breastfeed normally.
Treatment with Niplette or Nipple Stimulation.
Grade 2: Moderate Inversion
Moderately inverted nipples
It can be pulled out, but it immediately goes back in.
The milk ducts begin to shorten.
Partial connective tissue fibrosis.
Breastfeeding can be problematic.
Treatment: Niplette + Surgical correction (Preserving lactation)
Grade 3: Severe Inversion
Deeply indented nipples
It can't be pulled out.
Very short or atrophic milk ducts.
Connective tissue Severe fibrosis
Not breastfeeding.
Treatment: Surgical correction (may result in loss of lactation).
Paget's Disease of the Nipple — Cancer localized to the nipple.
Paget's disease is a rare form of breast cancer where cancer cells from DCIS, or invasive cancer, located beneath the breast, migrate to the surface of the nipple.
Symptoms of Paget's Disease
Nipple rash — red, itchy, peeling, like eczema.
Sores on the nipples — don't heal, bleed easily.
Peeling skin on the nipples
Severe itching of the nipples.
Pain, burning, stinging
Flat or indented nipples
Lymph/blood coming out of the nipple.
A lump may also occur in the same breast (80-90% of patients).
Paget's vs. Eczema — How to Differentiate Them
Eczema (skin disease):
Usually both sides.
Start with the areola and then move to the nipple.
Responded well to steroid cream (1-2 weeks).
Intermittent
The edges are blurry.
Paget's Disease (Cancer):
One-sided 95%+
Start with the nipple and then move to the areola.
Does not respond to steroid cream.
It's gradually getting worse; it won't go away on its own.
Clear edges
Thick peeling skin
⚠️ Important Rule: A rash/peeling on only one nipple that does not improve within 2 weeks after using steroid cream = A nipple punch biopsy is required to rule out Paget's Disease.
Other changes in the nipples to watch out for.
1. Nipple Retraction
Unlike inversion, retraction means the nipple is flattened or partially pulled inward. This is caused by a mass under the nipple that pulls Cooper's ligaments inward.
It is usually unilateral.
It just happened.
The nipple is angled toward the area with the lump.
You need a mammogram and ultrasound immediately.
2. Nipple Deviation (Slanted Nipple)
A nipple that is tilted to one side is always abnormal if it's only on one side and indicates a lump or fibroid pulling on the nipple.
3. Nipple Flattening
A nipple that was previously protruding has become flat. This is caused by a mass effect under the breast. Imaging is required.
4. Nipple Discharge (Lymphatic fluid from the nipple)
Lymphatic fluid, especially blood, coming from only one nostril is a sign that needs to be checked.
5. Skin changes around the nipple.
Red skin — Eczema, Mastitis, IBC, Paget's
Skin thickening — IBC, Locally Advanced Cancer
Skin peeling — Eczema, Paget's, Yeast infection
Orange peel skin — IBC
6. Color Changes (Nipple Color)
Darkening of the skin — Normal during pregnancy and postpartum, depending on hormones.
Pale white — Raynaud's phenomenon of the nipple, Vasospasm
Blue/purple — Mondor's disease, Cyanosis
Causes of Acquired Nipple Inversion
1. Breast Cancer
The most dangerous cause — nipple cancer — pulls Cooper's ligaments inward, causing the nipple to retract.
Invasive Ductal Carcinoma
Invasive Lobular Carcinoma
DCIS at a central location.
Inflammatory Breast Cancer
2. Duct Ectasia
Chronic dilation and inflammation of the milk ducts; commonly found in women aged 40-60 years; often accompanied by greenish-brown discharge; not cancerous.
3. Periductal Mastitis
Chronic inflammation around the milk ducts; found in smokers; often leads to periductal abscess and fistula.
4. Post-Surgical / Post-Trauma
After breast surgery, especially a lumpectomy near the nipple or reduction mammoplasty, capsular contracture (cavity retraction) may occur.
5. Tuberculosis Mastitis
Tuberculosis of the breast; found in countries where TB is prevalent; presents with a mass + sinus tract + axillary lymph nodes + chronic fever.
6. Aging Process
Age-related breast changes: Cooper's ligament prolapse + glandular tissue atrophy in older adults without other causes.
When should I see a doctor?
🚨 See a doctor within 1 week (Urgent)
Nipples that have recently inverted/retracted in adults.
The nipple is tilted to one side.
A rash/sore on the nipple that does not heal within 2 weeks.
Bloody fluid from the nipple.
A lump under the nipple or areola.
The skin on the nipple becomes thickened, red, or has an orange peel-like texture.
🟠 See a doctor within 2-4 weeks.
Nipples are becoming less flat or protruding.
Eczema-like rash on one nipple.
Severe and persistent itching at the nipples.
Lymph fluid that has changed color or pattern.
🟡 Consult a doctor within 1-3 months (if needed).
Congenital inversion that needs to be corrected for cosmetic reasons.
Congenital inversion for future breastfeeding.
Inversion that causes hygiene problems.
Before/After Visual Guide — How to properly examine your nipples yourself.
Step 1: Inspection (Looking in the mirror)
Position 1: Hands at your sides.
Stand in front of a mirror in a well-lit area.
Look at both nipples.
Compare symmetry — size, shape, position.
Observe whether the nipple is protruding (protrude) or inverted (inverted).
Check the direction — is it slanted to one side?
Observe the skin — peeling, redness, sores.
Position 2: Raise your arms above your head.
Cooper's ligaments will become tighter.
Indentations or retraction will become more visible.
Compare this to position 1.
Position 3: Contract your chest muscles.
Press your hands together on your chest.
Contract the pectoralis muscle.
Hidden indentations will become visible.
Suitable for detecting tethering.
Step 2: Palpating the nipples.
Use your index and middle fingers.
Feel around the nipple and under the areola.
Check for lumps.
Gently squeeze the nipple to check for lymphatic fluid (do this once a month — do not squeeze too often).
Record photographs
Take a picture of your nipples once a month from the same angle and under the same lighting.
Please help track the changes.
Show it to the doctor for comparison.
Store in a private folder.
Diagnostic testing
1. Clinical Examination
Examine and palpate both breasts.
Examine in a standing position, a lying position, and with the arms raised.
Assess the direction and movement of the nipple.
Feel under the nipple.
Examine the lymph nodes in the armpit.
2. Imaging
Mammogram — For ages ≥ 40 years · Detects microcalcifications.
Ultrasound — All ages · Check subareolar mass.
Breast MRI — Sensitive for Paget's and Occult cancer.
3. Skin Punch Biopsy of the nipple.
Required for Suspected Paget's Disease — 3-4 mm nipple biopsy · Local anesthesia · Pathology examination of Paget cells.
4. Core Needle Biopsy
If there is a lump under the nipple — perform an Ultrasound-guided Core Needle Biopsy. Also, review Histology and IHC (ER/PR/HER2).
5. Subareolar Duct Excision
If imaging is inconclusive but suspicion remains, surgical removal of the subareolar ducts may be necessary for diagnosis and treatment.
Treatment
Congenital Inversion — Treatment for Cosmetic Purposes / Breastfeeding
Niplette — Suction device, used continuously for 8 hours/day for 3 months. Good for Grade 1-2.
Manual stimulation — Stimulating the nipple to induce ejaculation.
Surgical correction — Preserving duct techniques (Grade 1-2) or Duct division (Grade 3)
Paget's Disease
Requires treatment similar to breast cancer:
Mastectomy (standard) — Removal of the entire breast.
Lumpectomy + Whole Breast Radiation — For DCIS limited to the nipple and surrounding area.
Sentinel Lymph Node Biopsy
Adjuvant therapy based on pathology findings.
Acquired inversion from breast cancer.
Depending on the type and stage of cancer — Lumpectomy + Radiation / Mastectomy + Reconstruction
Duct Ectasia / Periductal Mastitis
Antibiotics for acute infection
Major Duct Excision (Hadfield's procedure) if there are any bothersome symptoms.
Stop smoking.
Assessment of nipple replacement at Numarak Hospital.
As a specialized breast disease hospital, we have a team of doctors and the technology to carefully assess changes in the nipple.
Check-up services at Namarak.
Detailed clinical examination — by a fellowship-trained breast surgeon · Inversion grade assessment · Subareolar mass determination.
Hologic 3D Mammography + Genius AI — Detects Microcalcifications + Subareolar Masses
High-Resolution Breast Ultrasound — Provides a detailed view of the retroareolar area.
Skin punch biopsy of the nipple — in cases suspected of Paget's Disease · Performed in a laboratory.
Breast MRI — for Suspected Paget's
Multidisciplinary referral — Dermatologist for eczema-like rash.
Oncoplastic Surgery — If a mastectomy is necessary, treatment for the cosmetic outcome is also included.
Niplette + Surgical correction — for congenital inversion requiring correction.
High Tech, High Touch Philosophy
At Numarak Hospital , "it's like visiting a friend's house." This means we understand that changes in nipples can be a worrisome and personal matter — our medical and nursing team provides understanding care, offers detailed consultations, and plans appropriate diagnostic tests to reduce anxiety and boost confidence.
Frequently Asked Questions (FAQ)
Is it dangerous if nipples are inverted since childhood?
Harmless — Congenital nipple inversion occurs in 10-20% of women. It's a congenital condition caused by short milk ducts or connective tissue pulling the nipple inward. It doesn't increase the risk of breast cancer and can be treated for cosmetic reasons or to facilitate breastfeeding with Niplette or surgical correction.
Is it dangerous if my nipples started to retract at age 40?
Danger — Acquired nipple inversion in women aged 30-40 years is a significant red flag that requires evaluation within 1 week. Common causes include breast cancer, Paget's disease, ductal ectasia, and periductal mastitis. Mammogram, ultrasound, and biopsy are necessary if needed.
Does Niplette really work?
Effective in Grade 1-2 — Niplette is a suction device placed over the nipple that creates gentle suction to slowly pull the nipple out. It is used for 8 hours a day for 3 months and has a success rate of approximately 70-90% in Grade 1-2 cases, but is less effective in Grade 3, which requires surgery.
Does surgery to correct inverted nipples affect breastfeeding?
Depending on the technique used — Preserving duct techniques (for Grade 1-2) do not cut the milk ducts, allowing approximately 80-90% of patients to breastfeed normally. Duct division (for Grade 3) requires cutting the milk ducts, therefore breastfeeding is not possible. Therefore, if you plan to have children, you should inform your doctor before surgery.
Is Paget's Disease curable?
Depending on whether an invasive component is present, Paget's disease limited to the nipple (pure Paget's) or in combination with DCIS has a 5-year survival rate > 90%. For Paget's disease with co-occurring invasive cancer, the prognosis depends on the stage, grade, and molecular subtype of the invasive cancer. Overall, early detection and complete treatment lead to better outcomes.
Does it normal for nipples to flatten with age?
Normally, some changes in the breast with age (Cooper's ligaments, glandular atrophy) may cause the nipple to appear flatter in older women. Normally, both sides develop slowly and are asymptomatic. However, if there is rapid change in one side, or if there is a lump/fluid/skin change, further evaluation is necessary.
How to differentiate between eczema and Paget's disease (a rash on the nipples)?
Eczema usually affects both sides, starting in the areola, responds well to steroid cream within 1-2 weeks, and is relapsing. Paget's disease, on the other hand, is usually unilateral, starting in the nipple, does not respond to steroids, and gradually worsens. Important rule: If the nipple rash does not improve within 2 weeks of using steroid cream, a skin punch biopsy is required.
Is it dangerous if one nipple is tilted to one side?
Danger — Unilateral nipple deviation often indicates a lump or fibrous tissue under the breast that is pulling on the nipple. Immediate mammogram and ultrasound are necessary, especially in women over 40 with no history of breast surgery.
Consult a breast specialist at Numarak Hospital.
If you notice any changes in your nipples, especially if they are recently inverted/retracted/angled, or if you have a rash that doesn't go away, contact our medical team at:
Tel: 02-059-0245
LINE: @namarak (page.line.me/vfg3683z)
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About the editor.
Assoc. Prof. Yaowanuch Kongdan , M.D., Breast Surgeon + Surgical Oncologist · Founder and Director of Namarak Hospital · President of the Thai Breast Disease Society (TBS)
Note: This article is for general information only and cannot replace diagnosis and advice from a specialist. Changes in the nipple, especially those occurring in only one side in adults, should be evaluated by a breast specialist promptly.
References
Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plastic and Reconstructive Surgery 1999
NCCN Clinical Practice Guidelines—Breast Cancer (Version 2.2025)
Sukumvanich P et al. The role of skin biopsy in Paget's disease. Breast Cancer Research and Treatment 2008
Caliskan M et al. Paget's disease of the breast: diagnosis, treatment, and outcome. Breast Cancer Research and Treatment 2008
ACR BI-RADS Atlas 5th Edition — American College of Radiology
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