‘Black hole’ in breast dermatology

There is a black hole with respect to what differential diagnoses to consider when presented with a patient who has an abnormality of the nipple or areola, according to Margot S. Peters, M.D., professor of dermatology, Laboratory Medicine and Pathology at the Mayo Clinic College of Medicine in Rochester, Minn.

Margot S. Peters, M.D.Part of the problem is that dermatologists rarely see these patients, so there has been little attention in the dermatologic literature devoted to these problems, Dr. Peters says.

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Diagnostic considerations for lesions at these sites may include skin disorders as well as abnormalities of glandular breast tissue, particularly breast cancer, Dr. Peters says. Thus, rather than empirically treating with topical steroids, "Remember that what looks like nipple eczema could be breast cancer. The nipple is a window into the breast, representing the juncture where an interdisciplinary approach is needed."

Paget's disease represents 1-3% of primary breast cancers, and more than 95% of these patients have underlying invasive or in situ ductal carcinoma. However, Dr. Peters says, breast imaging studies may be negative in some patients, and a punch biopsy of the nipple abnormality may be diagnostic. Dermatologists thus can play a critical role in evaluation and diagnosis of women with breast abnormalities, she says.

Atopic eczema is the most common cause of bilateral itching of the nipple or nipple-areola area, and may occur without signs of dermatitis or itching at other sites.

Although benign neoplasms and cysts are more common than malignancies, she says, clinicians should have a high index for concern when a woman presents with a unilateral nipple problem. Common, benign lesions of the nipple-areola area include nipple adenomas, epidermal cysts and leiomyomas, Dr. Peters says. Paget's disease and metastatic carcinoma involving the nipple or areolar region almost always present unilaterally.

Dermatologists rarely see acute radiation dermatitis, but they should be aware of the delayed adverse effects of radiation therapy, such as telangiectasias, fibrosis and dyspigmentation, Dr. Peters says. Although post-radiation angiosarcoma occurs in less than 1% of patients who undergo radiation therapy for breast cancer, "Sometimes the distinction between progressive telangiectasias, atypical vascular lesions and angiosarcoma is difficult to make both clinically and pathologically."

NEXT: breast dermatology clinic

Breast dermatology clinic

To help narrow practice gaps, the Mayo Clinic Department of Dermatology established a Breast Dermatology Clinic, working collaboratively with the Breast Diagnostic Clinic at Mayo Clinic Rochester. A dedicated group of dermatologists participate in the evaluation of patients suspected to have Paget’s disease or metastatic breast cancer, side effects of radiation therapy and rashes or other lesions of the nipple, areola or breast skin. Most of the patients have undergone breast imaging studies prior to referral to a Breast Dermatology Clinic physician, according to Dr. Peters.

"It's important that the patient has had recent breast imaging, for practical and diagnostic reasons." The dermatologist should know, for example, if there is a particular area of concern underlying a visible or palpable abnormality, or if the mammogram is negative, before performing a biopsy, she says.

"Many of the patients referred to us have negative imaging, but there's still a clinical suspicion for breast cancer based on what's visible or palpable-such as redness of breast skin, or crusting of the nipple. Particularly when the imaging is negative, a skin biopsy may be the key to diagnosis."

Disclosure: Dr. Peters reports no relevant financial interests.

For additional reading:

Peters MS, Lehman JS, Comfere NI. Dermatopathology of the female breast. Am J Dermatopathol. 2013;35(3):289-304.