A 56-year-old woman comes to the office due to breast pruritus. The patient reports increasing pruritus around the right areola over the last 3 months that has not resolved with topical emollients. The pruritus is continuous and she is constantly scratching the breast. The patient has now noticed a lesion around the nipple and serosanguinous discharge on her clothing. She has had no change in skin products or detergents.
The patient has type 2 diabetes mellitus controlled with metformin. She has had no previous surgeries and has no known allergies. Her last mammogram, 2 years ago, was normal. The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal. The right breast has an ulcerative lesion over the right nipple and areola that does not extend to the surrounding tissue; there are no palpable masses or axillary lymph nodes. Serous fluid is expressed from the nipple. Examination of the left breast is unremarkable.
Which of the following is the most likely diagnosis in this patient?

Question

A 56-year-old woman comes to the office due to breast pruritus.  The patient reports increasing pruritus around the right areola over the last 3 months that has not resolved with topical emollients.  The pruritus is continuous and she is constantly scratching the breast.  The patient has now noticed a lesion around the nipple and serosanguinous discharge on her clothing.  She has had no change in skin products or detergents.
The patient has type 2 diabetes mellitus controlled with metformin.  She has had no previous surgeries and has no known allergies.  Her last mammogram, 2 years ago, was normal.  The patient does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  The right breast has an ulcerative lesion over the right nipple and areola that does not extend to the surrounding tissue; there are no palpable masses or axillary lymph nodes.  Serous fluid is expressed from the nipple.  Examination of the left breast is unremarkable.
Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_97eb_e7ba_853d_4d84e68d8817_MD0002_00 Paget disease of the breast (PDB) is characterized by a unilateral, erythematous, intensely pruritic, ulcerative lesion confined to the nipple and areola. Pain and burning occur prior to development of the lesion, which typically appears first on the nipple and migrates to the areola. There may be an associated serous or serosanguineous discharge. Nipple retraction can occur in patients with more advanced disease. Diagnosis of PDB is by tissue biopsy (eg, wedge, punch). Many patients with PDB have an underlying breast malignancy (eg, intraductal carcinoma, ductal carcinoma in situ). Therefore, all patients with PDB require bilateral mammography. (Choice A) Candida mastitis can present as a pruritic, erythematous areolar lesion; however, patients typically have deep, sharp pain out of proportion to the examination. Patients with diabetes mellitus are at risk of candidal infections; however, candidiasis, not mastitis, is typically located in intertriginous areas (eg, inframammary fold). inframammary fold (Choice B) Contact dermatitis typically presents with burning, pruritus, and erythema. Patients typically have recent irritant exposure (eg, change in detergent), and symptoms usually resolve with topical emollients. (Choice C) Ductal ectasia typically presents as a solitary breast mass with an associated thick nipple discharge due to a chronically inflamed, fibrotic subareolar duct. There is no pruritus or areolar erythema. (Choice D) Intraductal papilloma is a common cause of serosanguinous nipple discharge; however, patients do not typically have associated pruritus or skin changes (eg, erythema, ulcerations). Intraductal papilloma Educational objective: Paget disease of the breast is characterized by a unilateral, erythematous, intensely pruritic, ulcerative lesion of the nipple-areolar complex. Diagnosis is by tissue biopsy. Patients also require diagnostic bilateral mammography, as many have underlying breast malignancy. __________ References: Paget's disease of the nipple. (http://www.ncbi.nlm.nih.gov/pubmed/23929251) Paget's disease of the breast. (http://www.ncbi.nlm.nih.gov/pubmed/11237774) NCCN guidelines insights: breast cancer, version 1.2017. (http://www.ncbi.nlm.nih.gov/pubmed/28404755)

A 56-Year-Old Woman Comes to the Office Due to Breast