Any disorder of the skin can affect the breast. Some of the more important ones specific to the breast and nipple are discussed below.
Colonization of the nipples or the lactiferous ducts by Candida albicans may cause chronically sore nipples during or after lactation. The appearance of the nipple may be normal; however, more commonly, scaling, fissuring, and erythema are present. Predisposing factors for candidal colonization include antibiotic use, vaginal candidiasis, mastitis, and nipple trauma occurring in the early lactation period. Definitive diagnosis may be made by fungal culture, but that should not be necessary. The nipples may be treated with topical antifungal creams.4 Vaginal candidiasis in the patient, as well as any clinically evident oral candidiasis in the infant, should also be treated.
Atopic dermatitis, which may affect one or both nipples, is manifested by areas of fissuring, weeping skin, or lichenification. This condition occurs in both pregnant and nonpregnant women, most commonly between the ages of 15 and 30. This dermatitis is more common in atopic individuals. Underlying causes of these skin changes include scabies, contact allergy, local medication reaction, and irritation secondary to friction. 5
Paget's disease is an uncommon neoplastic disorder that usually begins at the nipple and spreads outward, secondarily involving the areola. This is an important distinction, since benign skin conditions begin on the areola. The appearance ranges from that of an eczema-like erosion of the nipple to a red, raw surface, with a copious, clear discharge. Both the areola and nipple have chronic, moist eczematous changes. Paget's disease is estimated to occur in 1 to 2 percent of breast cancers.4 Most cases are diagnosed in postmenopausal women. Unfortunately, early symptoms, such as an itching or burning sensation of the nipple, may be subtle and may have been present for years before the diagnosis is made. Paget's disease is usually unilateral. Patients may note a small crusted area, with staining of the clothing, or an overt serous or bloody discharge from the nipples. Dermatologic changes of the nipple and areola progress slowly. In later cases, there may be a sharply demarcated area on the nipple areola complex. The nipple may become retracted or deformed.
The histology of Paget's disease is an intraductal carcinoma occurring in the large sinuses beneath the nipple. The carcinomatous cells invade across the nipple epithelium. Paget's disease of the nipple has an associated palpable underlying mass in 50 percent of cases, and 90 percent of these patients have invasive intraductal carcinoma of the breast. Seventy percent of these patients without a palpable mass have in situ intraductal breast carcinoma; the remainder are diagnosed with invasive disease at a later date.6
Treatment for intraductal carcinoma associated with Paget's disease is related to the underlying carcinoma. The long-term outcome for treated patients is excellent. Referral to a breast surgeon is mandatory. Topical steroids should never be prescribed because the anti-inflammatory effects may delay the diagnosis.
Mondor's disease of the breast is a superficial phlebitis of the veins in the subcutaneous tissue of the breast. This condition may occur postoperatively or after minor trauma. The patient presents complaining of a painful induration across the costal margin. A cord may be present. The phlebitis may be tender for several weeks. No treatment other than analgesia is required. Follow-up evaluation with a surgeon is indicated. 4
An "orange-peel" appearance of the skin, or peau d'orange, is produced by skin edema emphasizing the skin sweat glands. Such a breast appearance indicates underlying breast carcinoma with both stromal infiltration and lymphatic obstruction, causing skin edema. Referral to a breast surgeon for appropriate diagnostic testing and treatment is always indicated.
Erosive adenomatosis of the nipple is an uncommon, benign tumor of the nipple that generally occurs in the fourth decade. It is a proliferation of the lactiferous ducts that usually occurs unilaterally but may occur bilaterally. The onset is insidious and may begin with a serous or bloody nipple discharge that worsens in the premenstrual period. Occasionally, there may be a palpable nodule, but usually the nipple appears eroded or eczematous. There is no accompanying axillary lymphadenopathy. The patient should be referred to a breast surgeon. Complete excision, which may include the entire nipple if it is involved, is curative.
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