Synopsis
Recognise persistent unilateral nipple epidermal change as possible underlying breast malignancy, secure skin and breast tissue diagnosis, and choose local treatment according to confirmed extent.
- Paget disease of the nipple is intraepidermal spread of malignant glandular cells and is usually associated with underlying ductal carcinoma in situ or invasive breast carcinoma.
- The classical lesion starts on one nipple and may extend to the areola, causing erythema, scaling, crusting, erosion, itch, pain, bleeding or flattening.
- Bilateral areolar dermatitis that spares the nipple and promptly improves with appropriate skin care is more typical of eczema; persistence or nipple involvement overrides that reassurance.
Key red flags
Persistent unilateral eczematous, crusted, ulcerated or bleeding change beginning on the nipple, especially with inversion, discharge or a breast mass, requires prompt breast assessment and tissue diagnosis.
Investigation priorities
Demonstrate malignant Paget cells within the epidermis and distinguish cancer from inflammatory dermatoses.
Management branches
A 63-year-old has four months of unilateral nipple crusting and bleeding that did not resolve with a topical steroid; no discrete mass is felt.
- Document whether change began on the nipple, its duration, discharge and prior treatment; inspect both nipple-areolar complexes and examine breast and regional nodes.
- Arrange diagnostic mammography and targeted retroareolar ultrasound rather than prescribing another empirical dermatological course.