A 55-year-old woman undergoes follow-up evaluation for a mildly pruritic eruption on and surrounding her right nipple, which developed about 5 months ago. Triamcinolone acetonide cream was begun 1 month ago with no improvement in the lesion. She has no personal or family history of eczema or psoriasis, and she is otherwise healthy. Her only medication is triamcinolone.
Breast findings are shown.
This patient has Paget disease of the breast, defined as a persistent, scaling, eczematous, or ulcerated lesion involving the nipple/areolar complex. Histologically, the hallmark of Paget disease of the breast is the presence of malignant, intraepithelial adenocarcinoma cells (Paget cells) within the epidermis of the nipple associated with an underlying invasive or intraductal cancer. It is often misdiagnosed on the first presentation as either eczema or psoriasis, but when there is a lack of response to appropriate therapy, a biopsy should be performed.
The most characteristic lesions of chronic cutaneous lupus erythematosus are discoid lesions appearing as erythematous, infiltrated plaques that are covered with scale and are associated with follicular plugging. These lesions are most often found on the face, neck, and scalp. As they expand, they develop depressed central scars. This patient's lesion, location, and appearance are not clinically compatible with chronic cutaneous lupus.
Lichen simplex chronicus is a localized disorder characterized by intense pruritus, which leads to a localized area of lichenified skin (thickened skin with increased and exaggerated skin markings due to scratching). This patient has no evidence of lichenification.
The most common form of psoriasis is plaque psoriasis. The skin lesions of this disorder are sharply demarcated, erythematous plaques covered by silvery-white scales that affect the scalp and extensor surfaces (elbows and knees) as well as the nails. A single patch of psoriasis located on the nipple would be a very rare presentation.
- Paget disease of the breast is a ductal carcinoma that presents as a persistent, scaling, eczematous, or ulcerated lesion involving the nipple/areolar complex and may be mistaken for more benign conditions such as eczema.