January 20, 2025

A 58-year-old woman presents with burning, itching, and scaling skin around her areola

By Med-Challenger · 1 minute read

A 58-year-old woman presents with a 1-month history of burning, itching, and scaling skin around her right areola. This presentation appears similar to contact dermatitis or eczema, and you prescribe a trial of 1% hydrocortisone ointment and recommend that she follow-up with you in 2 weeks.

On her return visit, there has been no significant improvement. In addition to mammography, the next diagnostic step would include which of the following?

referral to a breast surgeon for possible small excisional biopsy of areolar tissue to rule out lobular carcinoma in situ
course of empiric antibiotics to treat a superimposed infectious component
referral to a breast surgeon for possible small excisional biopsy of areolar tissue to rule out Paget disease and associated ductal carcinoma in situ
referral to a breast surgeon for possible small excision of the involved duct to rule out duct ectasia

The correct answer is:

referral to a breast surgeon for possible small excisional biopsy of areolar tissue to rule out Paget disease and associated ductal carcinoma in sit

Educational Objective:

Diagnose Paget disease of the breast.

Key Point:

Paget disease of the breast is an eczematous lesion of the nipple and areola areas associated with an underlying breast carcinoma.

Explanation:

This clinical presentation is consistent with Paget disease of the nipple, which, in the majority of cases, is associated with an underlying malignancy (in situ or invasive breast cancer) upon further radiographic evaluation. Duct ectasia is possible and is associated with itching and burning, but it is usually accompanied by multiduct nipple discharge with or without nipple inversion and without significant inflammatory findings. Lobular carcinoma in situ is usually not detectable by clinical examination and is more often an incidental finding in a breast biopsy specimen.

References:

Alvero R, Paget’s disease of the breast. In: Ferri FF. Ferri's Clinical Advisor. 2017:915.

Harris JR, et al, eds. Diseases of the Breast. 5th ed., 2014.

This question appears in Med-Challenger Internal Medicine Exam Review with CME

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