45-year-old woman presents with erythematous weeping lesion of left nipple.
How long have you had this lesion?
I first noticed a little redness of the nipple about 6 months ago. It waxed and waned. For the past six weeks, it has been persistent and spreading.
Good question; the course of the lesion often helps with the diagnosis.
Have you had discharge from the nipple?
Yes, every so often there is a little discharge.
Good question. Nipple discharge can reflect galactorrhea or an intraductal breast carcinoma. The fluid itself may cause an irritant contact dermatitis.
Did you have eczema, hay fever or asthma as a kid, or later on?
Good question. The nipples are a common site for atopic dermatitis, but the involvement is usually bilateral.
Are you nursing now?
Good question. Many nursing mothers have an irritant nipple dermatitis.
Have any women in your gamily had or died from breast cancer?
Yes, my m other died from breast cancer.
Good question. The genetic background of breast cancer is important.
Are you taking any medications?
Good question. Some medications lead to galactorrhea. In addition, long-term use of oral contraceptives is one risk factor for breast cancer.
Choose the right efflorescences:
Macule is a flat lesion; this lesion is palpable.
Lichenification is caused by persistent rubbing and features exaggerated skin markings. There is more here.
Actually this is a plaque, a broad flat lesion, but in the papule family.
Choose the right diagnosis:
Careful. This is part of the differential diagnosis but is usually less circumscribed. The history does not support this choice.
The lesion could represent psoriasis if the patient had widespread disease, but psoriasis never presents as a solitary nipple plaque.
Herpes simplex can involve the nipple following oral-nipple contact, but lesions are vesicular, then crusted, and temporary.
Unilateral nipple dermatitis in a non-atopic, non-nursing women is always Paget disease until proved otherwise. The first step is a biopsy. Paget disease reflects an underlying ductal carcinoma of the breast which has spread to the nipple.
Choose the right therapy(ies):
Wrong and dangerous. The underlying breast cancer must be treated.
Destroying a few superficial cells is not the answer.
The only way to go!!
This is the trap. Do not treat a unilateral nipple dermatitis as such unless Paget disease has been excluded.