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Reynaert V, Gutermuth J, Wollenberg A. Nipple eczema: A systematic review and practical recommendations. J Eur Acad Dermatol Venereol 2023; 37:1149-1159. [PMID: 36695082 DOI: 10.1111/jdv.18920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
The nipple is the focal point of the human breast and serves important physiological, sexual, and aesthetic purposes. It can be affected by atopic, irritant, and allergic contact eczema, which often reduce the patient's quality of life. The objective of this article is to discuss the different types of nipple eczema and highlight relevant differential diagnoses and treatment options. A systematic search of PubMed was conducted to identify and critically appraise the existing literature on the topic. All articles on nipple eczema were considered eligible, regardless of publication date, language or study design. A final of 33 manuscripts on nipple eczema remained. The scarce literature and the limited number of high-quality manuscripts impedes provision of structured data on nipple eczema. To securely reach the educative value of this manuscript, the systematic review was combined with a manual databank search and selected manual search of textbooks. The differential diagnosis of nipple eczema encompasses among others nipple psoriasis, nipple candidiasis and Paget's disease. In case of diagnostic uncertainty, swabs or biopsies are indicated. Treatment of nipple eczema needs to rapidly control the signs and symptoms of the disease, since it can have a negative effect on quality of life and can lead to premature arrest of breastfeeding. The key treatment step is starting with topical corticosteroids or calcineurin inhibitors, both of which are considered safe during lactation. Avoidance of provoking factors, such as repetitive friction, chemical agents, or allergens, can help. The use of nipple protection devices can be proposed for nursing women and sometimes adjusting of latch/suck positioning during breastfeeding is needed. Furthermore, patients should be advised to moisturize the nipple intensively and to switch to emollient wash products. Warm water compresses, black tea compresses or commercially available tannin containing topicals can provide comfort.
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Affiliation(s)
- V Reynaert
- Department of Dermatology, SKIN Research Group, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - J Gutermuth
- Department of Dermatology, SKIN Research Group, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - A Wollenberg
- Department of Dermatology, SKIN Research Group, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.,Department of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
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Ogata H, Mitsuzuka Y, Honma N, Yoshida M, Sumazaki M, Saito F, Kobayashi M, Shibuya K, Mikami T, Kaneko H. Sonographic visualization of nipple blood flow can help differentiate Paget disease from benign eczematous nipple lesions. PLoS One 2018; 13:e0197156. [PMID: 29768474 PMCID: PMC5955580 DOI: 10.1371/journal.pone.0197156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/27/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose Paget disease of the breast is a rare cancer that originates from the nipple–areolar complex. It is often overlooked and misdiagnosed as benign chronic eczema of the nipple. We aimed to retrospectively verify whether blood flow analysis using Doppler sonography was useful for detecting the presence of Paget disease. Methods In this retrospective study, 12 patients with pathologically proven unilateral nipple eczematous lesions (seven with Paget disease and five with simple dermatitis) were included. Nipple blood flow signal was observed using Doppler sonography, and the detected blood flow signals were quantified using digitally recorded images. Quantified blood flow ratio and pathologically examined capillary density were evaluated between affected and unaffected nipples. Findings of mammography, grayscale sonography, and contrast-enhanced magnetic resonance imaging (CE-MRI) were reviewed. Results In patients with Paget disease, Doppler effects in the affected nipple were more clearly visible than those in the unaffected nipple. These effects were sufficiently visible to identify Paget disease. No obvious effects were observed in the affected and unaffected nipples of simple dermatitis. The quantified blood flow ratio and pathologically examined capillary density were significantly higher for the Paget lesion than those for the non-Paget lesion. The sensitivity of CE-MRI and Doppler sonography was markedly correlated, revealing blood flow changes in the nipple lesions of Paget disease. Conclusion Doppler sonography visualized the proliferation of blood vessels in Paget lesions. The visualization of increased nipple blood flow using Doppler sonography is a simple and low-cost method that provides useful data for identifying Paget disease during routine medical care.
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Affiliation(s)
- Hideaki Ogata
- Division of Breast and Endocrine Surgery (Omori), Department of Surgery, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
- * E-mail:
| | - Yukio Mitsuzuka
- Department of Clinical Physiology, Toho University Medical Center Omori Hospital, Omorinishi, Ota-ku, Tokyo, Japan
| | - Naoko Honma
- Department of Pathology, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Miho Yoshida
- Division of Breast and Endocrine Surgery (Omori), Department of Surgery, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Makoto Sumazaki
- Division of Breast and Endocrine Surgery (Omori), Department of Surgery, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Fumi Saito
- Division of Breast and Endocrine Surgery (Omori), Department of Surgery, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Masahiro Kobayashi
- Department of Radiology, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Kazutoshi Shibuya
- Department of Surgical Pathology, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Tetsuo Mikami
- Department of Pathology, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
| | - Hironori Kaneko
- Division of Breast and Endocrine Surgery (Omori), Department of Surgery, School of Medicine, Toho University, Omorinishi, Ota-ku, Tokyo, Japan
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Sripathi S, Ayachit A, Kadavigere R, Kumar S, Eleti A, Sraj A. Spectrum of Imaging Findings in Paget's Disease of the Breast-A Pictorial Review. Insights Imaging 2015; 6:419-29. [PMID: 26142549 PMCID: PMC4519816 DOI: 10.1007/s13244-015-0415-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/08/2015] [Accepted: 06/12/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We aimed to demonstrate imaging features of Paget's disease of breast, which is an extremely uncommon malignancy that presents with changes in the nipple-areolar region that may or may not be associated with an underlying in situ component or invasive cancer. METHODS AND RESULTS Mammography is the initial investigation of choice, having a high sensitivity especially in cases where a palpable mass is present. The addition of ultrasound improves the accuracy of mammography. When both mammography and ultrasound are negative, MRI may detect an underlying mass or ductal carcinoma in situ (DCIS). CONCLUSION The surgical management of Paget's disease includes mastectomy with or without axillary dissection, though breast conservation surgery in the form of wide local excision can also be done in a selected group of patients. Management should be based on both clinical and imaging findings, including mammography and ultrasound, with MRI playing a crucial role in defining the extent of involvement. Teaching Points • To differentiate Paget's disease from other chronic skin conditions. • Mammographic and ultrasound findings of histopathologically established Paget's disease. • When ultrasound and mammogram are negative, MRI may detect underlying malignancy.
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Affiliation(s)
- Smiti Sripathi
- Department of Radiodiagnosis and Imaging, Kasturba Medical College, Manipal, Karnataka, India,
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Song HS, Jung SE, Kim YC, Lee ES. Nipple Eczema, an Indicative Manifestation of Atopic Dermatitis? A Clinical, Histological, and Immunohistochemical Study. Am J Dermatopathol 2015; 37:284-8. [DOI: 10.1097/dad.0000000000000195] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Julián-Gónzalez RE, Orozco-Covarrubias L, Durán-McKinster C, Palacios-Lopez C, Ruiz-Maldonado R, Sáez-de-Ocariz M. Less common clinical manifestations of atopic dermatitis: prevalence by age. Pediatr Dermatol 2012; 29:580-3. [PMID: 22469300 DOI: 10.1111/j.1525-1470.2012.01739.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The common manifestations of atopic dermatitis (AD) appear sequentially with involvement of the cheeks in infancy, flexural extremities in childhood, and hands in adulthood. Although less common clinical manifestations are well described, they have not been the subject of epidemiologic studies to describe their prevalence in specific age groups. This observational, cross-sectional, comparative study included 131 children younger than 18 of both sexes with AD who attended the clinics of the Dermatology Department of the National Institute of Pediatrics in Mexico City. Patients were examined to determine the presence of infrequent clinical manifestations of AD during infancy, preschool and school age, and adolescence and stratified according to sex, age, and number of clinical signs. A chi-square test was used to detect differences according to age and sex. Logistic regression analysis was also performed. The main findings according to age were genital dermatitis and papular-lichenoid dermatitis variant in infants; atopic feet, prurigo-like, nummular pattern, and erythroderma in preschool and school-aged children; and eyelid eczema and nipple dermatitis in adolescents. The risk of development of nipple dermatitis and eyelid eczema increased with age, and the development of genital dermatitis decreased with age. The knowledge of the prevalence of less common clinical manifestations of AD according to age in different populations might be helpful in diagnosing incipient cases of AD.
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Lim HS, Jeong SJ, Lee JS, Park MH, Kim JW, Shin SS, Park JG, Kang HK. Paget disease of the breast: mammographic, US, and MR imaging findings with pathologic correlation. Radiographics 2012; 31:1973-87. [PMID: 22084182 DOI: 10.1148/rg.317115070] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Paget disease is a rare malignancy of the breast characterized by infiltration of the nipple epidermis by adenocarcinoma cells. The clinical features of Paget disease are characteristic and should increase the likelihood of the diagnosis being made. An important point is that more than 90% of cases of Paget disease are associated with an additional underlying breast malignancy. Paget disease is frequently associated with ductal carcinoma in situ (DCIS) in the underlying lactiferous ducts of the nipple-areolar complex; it may even be associated with DCIS or invasive breast cancer elsewhere in the breast, at least 2 cm from the nipple-areolar complex. Nevertheless, mammographic findings may be negative in up to 50% of cases. Magnetic resonance (MR) imaging can be useful in patients with Paget disease for evaluation of the nipple-areolar complex and identification of an additional underlying malignancy in the breast. The appropriate surgical treatment must be carefully selected and individualized on the basis of radiologic findings, especially those obtained with breast MR imaging.
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Affiliation(s)
- Hyo Soon Lim
- Department of Radiology, Chonnam National University Medical School, 8 Hack Dong, Dong Ku, Gwangju 501-757, South Korea.
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Cosechen MS, Wojcik ASDL, Piva FM, Werner B, Serafini SZ. Erosive adenomatosis of the nipple. An Bras Dermatol 2012; 86:S17-20. [PMID: 22068761 DOI: 10.1590/s0365-05962011000700003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 11/22/2010] [Indexed: 11/21/2022] Open
Abstract
Erosive adenomatosis of the nipple is a complex benign mammary proliferation that can be misdiagnosed as a malignant mammary neoplasm. The most common clinical presentation includes discharge, erythema, erosion and crusting. The process is usually asymptomatic. It resembles benign conditions such as contact dermatitis, psoriasis and infections, but its main differential diagnosis is Paget's disease. Treatment is usually surgical and the prognosis is excellent.
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Abudu EK, Umanah IN, Ekpo MD, Etuk EB, Onwuezobe IA, Obi-Ihesie A. A giant ectopic hidradenoma papilliferum in a Niger delta region of Nigeria. Rare Tumors 2011; 3:e50. [PMID: 22355505 PMCID: PMC3282455 DOI: 10.4081/rt.2011.e50] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 10/05/2011] [Accepted: 10/10/2011] [Indexed: 11/24/2022] Open
Abstract
Hidradenoma papilliferum is a known example of adnexal skin tumours with apocrine differentiation. It is a rare benign tumour which tends to arise from areas with rich concentration of aporine glands such as anogenital region, vulval, perineal, axillae, and periumbilical areas. In this report, the tumour was found in the upper outer quadrant of left breast, being one of the ectopic sites for this tumour. Contrary to most reports where male preponderance was popular for ectopic hidradenoma papilliferum, the patient in this report is a 71-year-old female. Considering the location of this tumour in this report, the likely histopathological differential diagnoses such as tubular apocrine adenoma, clear cell (apocrine) adenoma, lipoma, intraductal papilloma and papillary carcinoma of the breast should be considered for exclusion. This is the first reported case of a giant ectopic hidradenoma papilliferum of the breast in a Niger Delta region of Nigeria which also highlights the role of fine needle aspiration and cytology in the diagnosis of breast lesions.
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Günhan-Bilgen I, Oktay A. Paget's disease of the breast: Clinical, mammographic, sonographic and pathologic findings in 52 cases. Eur J Radiol 2006; 60:256-63. [PMID: 16887314 DOI: 10.1016/j.ejrad.2006.06.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 06/27/2006] [Accepted: 06/28/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE To determine and quantitate radiologic characteristics of Paget's disease of the breast and to report clinical and pathologic findings. MATERIALS AND METHODS A retrospective review of records of 2872 women who received a diagnosis of breast carcinoma between January 1988 and January 2006 revealed 52 histologically proved Paget's disease of the breast. Analysis included history, findings at physical examination, mammography and sonography (US) and histologic type of Paget's disease. RESULTS At physical examination, palpable mass (n=33, 63%), nipple erythema-eczema-ulceration (n=17, 33%) and blood-stained nipple discharge (n=5, 10%) were noted. Among 17 patients who had clinically evident Paget's disease, the mammographic findings were isolated microcalcifications in 3 (18%), mass associated with microcalcifications in 5 (29%), mass in 2 (12%) and negative in 7 (41%) patients. In the 35 patients with clinically inevident Paget's disease, these mammographic findings were 43% (n=15), 34% (n=12), 20% (n=7) and 3% (n=1), respectively. US depicted 43 masses in 35 patients, all of which were lobulated or irregularly contoured, mostly (n=41, 95%) without posterior acoustic shadowing. The cancer was clinically occult in 10% (n=5), mammographically occult in 15% (n=8) and radiologically occult in 13% (n=7) of the 52 patients. Histologically, the tumor was multifocal and/or multicentric in 11 (21%) patients. CONCLUSION The clinical features of Paget's disease are characteristic and should alert the clinician to the likelihood of an underlying carcinoma, which should be evaluated radiologically. However, as Paget's disease is primarily a clinical diagnosis and mammograms may be negative, screening programs without clinical examination may result with delay in diagnosis. As a result, both clinical and imaging findings are complementary and should be correlated to confirm or exclude a diagnosis of Paget's disease.
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Affiliation(s)
- Işil Günhan-Bilgen
- Ege University Hospital, Department of Radiology, Bornova 35100, Izmir, Turkey.
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Abstract
We present an 11-year-old girl, with celiac disease, and a 9- month history of itchy and erythemato-edematous lesions with vesicles and exudation on her nipples and areolas. No other lesions or signs of scratching were present on her face or folds. She had no specific lesions of atopic dermatitis in typical sites nor in other body surface during her life. Patch tests showed a positive reaction to nickel and thimerosal that was not significantly related to the clinical appearance. This presentation documents the clinical relevance of atopic dermatitis minor diagnostic criteria. We discuss the importance of nipple eczema in AD and its differential diagnosis.
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Affiliation(s)
- Laura Amato
- Department of Dermatological Sciences, University of Florence, Italy
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Fernández-Aceñero MJ, Sánchez TA, Sánchez MCV, Requena L. Ectopic hidradenoma papilliferum: a case report and literature review. Am J Dermatopathol 2003; 25:176-8. [PMID: 12652207 DOI: 10.1097/00000372-200304000-00024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lambiris AG, McCormick F. Unilateral hyperkeratosis of nipple and areola associated with androgen insensitivity and oestrogen replacement therapy. J Eur Acad Dermatol Venereol 2001. [DOI: 10.1046/j.0926-9959.2001.00150-6.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- N Kapur
- Department of Dermatology, The Whittington Hospital, Highgate Hill, London N19 5NF, UK
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Lambiris AG, McCormick F. Unilateral hyperkeratosis of nipple and areola associated with androgen insensitivity and oestrogen replacement therapy. J Eur Acad Dermatol Venereol 2001. [DOI: 10.1046/j.1468-3083.2001.00150-16.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Paget's disease of the breast is a rare disorder of the nipple-areola complex that is often associated with an underlying in situ or invasive carcinoma. A change in sensation of the nipple-areola, such as itching and burning, is a common presenting symptom. Objectively, eczematoid changes of the nipple-areola complex are common. The later stages of Paget's disease of the breast are characterized by ulceration and destruction of the nipple-areola complex. Eczematoid changes of the nipple-areola complex and persisting soreness or itching, without obvious reason, is a suspicious symptom for Paget's disease of the breast and calls for thorough evaluation, including mammography. Exfoliative cytology with demonstration of Paget's cells may be useful, but a negative finding does not exclude Paget's disease of the breast. Surgical biopsy is the diagnostic standard and therefore the diagnosis should always be confirmed by open (surgical) biopsy. The histogenesis of Paget's disease of the breast continues to be debated. The epidermotropic theory holds that Paget's cells are ductal carcinoma cells that have migrated from the underlying breast parenchyma to the nipple epidermis. According to the in situ transformation theory, the Paget's cells arise as malignant cells in the nipple epidermis independent from any other pathologic process within the breast parenchyma. This theory has been proposed to explain those cases in which there is no underlying mammary carcinoma or when there is a carcinoma remote from the nipple-areola complex. Each of these theories is plausible; however, treatment approaches differ markedly depending on the theory of histogenesis. Mastectomy has been considered the standard of care in the management of patients with Paget's disease of the breast. Nowadays, however, some patients with Paget's disease of the breast are candidates for breast-conserving therapy. Patients must be selected carefully on an individual basis. Until there is a better understanding of the relationship of Paget's disease of the breast to the underlying cancer the surgeon should understand the natural history and behaviour of this lesion and be aware of both the risks of under- and over-treating patients with Paget's disease of the breast.
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Affiliation(s)
- G H Sakorafas
- Department of Surgery, 251 Hellenic Air Force General Hospital, GR--115 25 Athens, Greece.
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Whitaker-Worth DL, Carlone V, Susser WS, Phelan N, Grant-Kels JM. Dermatologic diseases of the breast and nipple. J Am Acad Dermatol 2000; 43:733-51; quiz 752-4. [PMID: 11050577 DOI: 10.1067/mjd.2000.109303] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Breast and nipple skin is commonly affected by various inflammatory and neoplastic processes. Despite this fact, many physicians are unaware of the spectrum of diseases that can involve this area. Because breast and nipple skin represents a cosmetically, sexually, and functionally important entity to most patients, awareness of these disease entities is invaluable. This article reviews the normal anatomy of the breast, cutaneous manifestations of neoplastic processes that can present in these areas, and common inflammatory diseases of the breast and nipple skin.
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Affiliation(s)
- D L Whitaker-Worth
- University of Connecticut School of Medicine, Department of Dermatology, Farmington, USA.
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