Photo Rounds

Breast rash

A 29-year-old woman asked her family physician (FP) to look at the rash on her breast that had been there for 8 months. Various creams and lotions hadn’t helped. The FP noted marked reddening of the nipple and scaling, but no palpable breast masses or lymph nodes.

What's your diagnosis?


 

The FP was concerned about Paget disease of the breast and performed a 4 mm punch biopsy of the affected area, including a portion of the nipple. The pathology confirmed the diagnosis.

Paget disease of the breast is a low-grade malignancy that is often associated with other malignancies. It presents clinically in the nipple-areolar complex as a dermatitis that may be erythematous, eczematous, scaly, raw, vesicular, or ulcerated. The nipple is usually initially involved, and the lesion then spreads to the areola.

Most patients delay presentation (median 6-8 months), assuming the abnormality is benign. Presenting symptoms are sometimes limited to persistent pain, burning, and/or pruritus of the nipple. A palpable breast mass is present in half of all cases, but is often located more than 2 cm from the nipple-areolar complex. Twenty percent of cases will have a mammographic abnormality without a palpable mass, and 25% of cases will have neither a mass nor abnormal mammogram, but will have an occult ductal carcinoma.

The treatment and prognosis of Paget disease of the breast is first based on the stage of any underlying breast cancer. Simple mastectomy has traditionally been the standard treatment for isolated Paget disease of the breast. Breast-conserving surgery combined with breast irradiation is gaining wider acceptance.

In this case our patient chose to have a simple mastectomy with a transverse rectus abdominis muscle (TRAM) flap reconstruction.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Paget disease of the breast. In: Usatine R, Smith M, Mayeaux EJ, et al,eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:557-560.

To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: http://usatinemedia.com/

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