QuestionSBA
QuestionChoice
This would be an appropriate strategy to manage shingles. There is no suggestion of a rash present in a dermatomal distribution, or any vesicles. The unilateral nipple findings are concerning for Paget's disease of the nipple.
10017334
d
Oral aciclovir and steroids
QuestionChoice
While the red, scaly rash may look eczematous, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
10017332
b
Topical steroid ointment
QuestionChoice
While the red, scaly rash may look like a fungal infection, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
10017335
e
Topical miconazole cream
QuestionChoice
While the red, scaly rash may look eczematous, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
10017333
c
Topical emollient cream and follow-up in 2 weeks
QuestionChoice
The patient's symptoms and examination findings suggest Paget's disease of the nipple, a condition that is frequently associated with ductal carcinoma of the breast. This should not be mistaken for eczema or an infection. NICE recommend a 2-week referral for women aged over 50 with unilateral nipple changes that are concerning. A triple assessment will involve imaging (likely a mammogram), examination, and biopsy.
10017331
a
Referral on 2-week-wait pathway for triple assessment
Concept
Chapter
# Summary
 

Paget's disease of the nipple is a rare form of breast cancer that initially presents with eczema-like changes to the nipple and areola. Main signs and symptoms include a crusty, inflamed rash on the nipple and areola, bloody nipple discharge, pain, and nipple retraction or inversion. On occasions, a palpable breast lump or unhealing skin ulcer may also be present. Key investigations involve a physical examination, mammography, ultrasound, and biopsy to confirm the diagnosis. Management primarily involves surgical interventions such as mastectomy, along with radiation and hormonal therapies depending on the underlying cancer's nature.
 

# Definition
 

Paget's disease of the nipple, also known as Paget's disease of the breast, is a rare condition characterised by the presence of cancer cells in the skin of the nipple. This disease often suggests an underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.
 

# Epidemiology
 

Paget's disease of the nipple is a rare disorder, accounting for less than 5% of all breast cancer cases. It is most commonly seen in postmenopausal women, but it can occur in men and women of any age.
 

# Aetiology
 

The exact cause of Paget's disease of the nipple is not fully understood. There are two main theories: the epidermotropic theory, which suggests that cancer cells from an underlying breast tumour migrate to the nipple; and the intraepidermal origin theory, which proposes the disease originates in the nipple itself.
 

# Signs and Symptoms
 

Common clinical features of Paget's disease of the nipple include:
 

-  Eczema-like rash on the skin of the nipple and areola that is often itchy, red, crusty, and inflamed
-  Bloody nipple discharge
-  Burning sensation, increased sensitivity, or pain in the nipple
-  Changes to the nipple, such as retraction or inversion
-  Palpable breast lump (in some cases)
-  Non-healing skin ulcer (in some cases)
 

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# Differential Diagnosis
 

When assessing Paget's disease of the nipple, the main differential diagnoses include:
 

-  **Atopic dermatitis (eczema)**: characterised by itchy, red, and inflamed skin, usually occurring in patches
-  **Contact dermatitis**: caused by irritants or allergens, presents with a red rash, itching, and possibly blisters
-  **Intraductal papilloma**: produces bloody nipple discharge but typically does not involve skin changes
-  **Mastitis or breast abscess**: presents with breast redness, swelling, pain, and possible fever; often related to breastfeeding
-  **Psoriasis**: presents with silvery scales on red, raised patches, often with itching or burning
 

# Investigations
 

To diagnose Paget's disease of the nipple, the following investigations are typically carried out:
 

-  Physical examination of the breasts and lymph nodes
-  Mammography or breast ultrasound
-  Biopsy of the affected skin and nipple discharge cytology
-  MRI may be used in certain circumstances to better assess the extent of disease
 

# Management
 

Management of Paget's disease of the nipple primarily involves surgical intervention and is guided by the presence and extent of underlying breast cancer. Approaches can include:
 

-  Simple mastectomy: Removal of the entire breast, including the nipple and areola
-  Modified radical mastectomy: Removal of the entire breast along with some of the axillary (underarm) lymph nodes
-  Breast-conserving surgery (lumpectomy): If the underlying cancer is small and limited
 

Additionally, adjunctive treatments such as radiation therapy, chemotherapy, or hormonal therapy may be used depending on the characteristics of the underlying breast cancer.
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Picture
The typical appearance of Paget's disease of the nipple.
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Paget's disease of the nipple
Topic
55
Breast Disease
16010
Paget's disease of the nipple often indicates underlying breast cancer and requires a 2 week wait refferal
A 54 year old woman attends her GP with an itchy nipple. On examination, she has a raised, scaly, red rash extending to the areola. There is no nipple inversion or discharge. Examination of both breasts is otherwise normal.

What is the most appropriate next step?
a