By vgreene, 2 June, 2021

DOAC

(BMJ)—A man in his 50s with a 1-month hx of an exudating, swollen, itchy R nipple was referred to the breast surgery clinic. He had hx of hay fever but no known recent contact with irritants/allergens. Exam: R nipple-areolar complex red, thickened, excoriated. No palpable lumps or axillary nodes. L nipple WNL. No other lesions. What’s the dx?
Candidal infection
Basal cell carcinoma
Atopic dermatitis
Papillary adenoma of the nipple
Paget disease of the nipple
You are correct. Mammography and U/S showed only thickened R areolar skin, while punch bx revealed epidermal hyperplasia, hyperkeratosis/parakeratosis, and subepithelial inflammation, confirming the dx of atopic dermatitis. Histology is the ideal approach for diagnosing (and excluding) malignant transformation in the breast.

Candidal infection is more common in patients who are immunocompromised or lactating, while papillary adenoma usually affects middle-aged women.

In this patient, eczema of the nipple-areolar complex resolved completely after tx with emollients and topical steroids.

BMJ 2021;373:n750