From the Guidelines
For an 88-year-old patient with bilateral nipple pain lasting 4 months, the best course of action is to seek prompt medical evaluation by a primary care physician or geriatrician to rule out serious conditions like Paget's disease or breast cancer. The initial management should include a thorough physical examination to assess for visible changes such as redness, scaling, discharge, or masses. Topical emollients like petroleum jelly or lanolin cream can be applied to the nipples 2-3 times daily to relieve dryness and irritation, as suggested by general medical practice. Wearing loose-fitting, cotton clothing and avoiding harsh soaps or detergents may help reduce friction and irritation. If the examination reveals no concerning findings, a trial of low-potency topical corticosteroid such as hydrocortisone 1% cream applied sparingly twice daily for 7-10 days may be appropriate. However, given the patient's advanced age and the prolonged duration of symptoms, further investigation is warranted, potentially including diagnostic imaging such as mammography or ultrasound, as recommended by the NCCN guidelines 1. The risk of cancer in a woman presenting with breast pain as the only symptom is low, but it is crucial to investigate further, especially in elderly patients, to rule out conditions like Paget's disease, which may present with nipple pain and has a significant association with underlying breast cancer 1. The physician may also need to review all medications as some can cause breast tissue changes or discomfort as side effects. Key considerations in the management of this patient include:
- Thorough physical examination
- Diagnostic imaging if necessary
- Symptomatic management of breast pain
- Review of medications for potential side effects Given the most recent and highest quality study available 1, the approach should prioritize a comprehensive evaluation and symptomatic management, with further investigation as needed to rule out serious underlying conditions.
From the Research
Diagnosis and Management of Nipple Pain
The patient's symptoms of bilateral nipple pain lasting 4 months require a thorough evaluation to determine the underlying cause.
- The differential diagnosis for nipple pain includes eczema, dermatitis, and Paget's disease of the breast, a rare cancer that typically affects postmenopausal women 2, 3, 4.
- Paget's disease of the breast often presents with skin changes, a lump, nipple discharge, pain, and changes to the nipple shape, and is associated with an underlying malignancy 4.
- The diagnosis of Paget's disease can be challenging, as it may masquerade as other benign and malignant dermatological conditions, including eczema, atopic dermatitis, psoriasis, and squamous and basal cell carcinomas 5.
Diagnostic Approach
- A thorough physical examination and assessment of the patient's risks and symptoms are essential in evaluating common breast problems, including nipple pain 6.
- Imaging options, such as ultrasound, mammogram, and magnetic resonance imaging (MRI), can help identify an underlying cancer and guide surgical management 3, 4, 5.
- A tissue core biopsy is the definitive diagnostic investigation for Paget's disease of the breast 4.
- The use of MRI is recommended as a superior and more accurate imaging tool, particularly in cases lacking a palpable lump 5.
Management Options
- Management options for Paget's disease of the breast typically involve surgical interventions, including breast-conserving surgery or mastectomy, as well as oncoplastic techniques 4.
- Adjuvant chemotherapy, radiotherapy, or endocrine therapy may be used to treat concomitant invasive disease or ductal carcinoma in situ 4.
- A multidisciplinary team approach is recommended to decide on the optimal management strategy for each patient 4.