While the FP was initially concerned about Paget disease of the breast, he ultimately ruled that out because of the lack of red flags, such as ulcerations, breast masses, or palpable lymph nodes. The more likely diagnosis: eczema of the nipple and areola.
When the FP obtained a more detailed history, the patient admitted to having an inverted nipple her whole adult life and remembered having had some difficulty breastfeeding her children from this breast. The FP ordered a mammogram and prescribed triamcinolone ointment 0.1% to be applied once to twice daily as needed. The mammogram was negative.
During a follow-up visit 3 weeks later, the skin of the nipple and areola appeared normal with no change in the nipple inversion. The FP educated the patient about Paget disease of the breast and told her that if her rash did not continue to resolve with the topical medicine, she should return for a biopsy. The patient was also given the option to have the biopsy done right away, but she preferred to avoid the surgical procedure.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Paget disease of the breast. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:557-560.
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