What is the workup for a patient presenting with dry flaky nipples?

Workup for Dry Flaky Nipples

The workup for dry flaky nipples should first distinguish between physiologic conditions and pathologic causes, with nipple eczema being a common benign cause requiring topical corticosteroids or calcineurin inhibitors as first-line treatment. 1

Initial Assessment

History

• Determine if discharge is present:
  • If present, characterize as physiologic or pathologic:
    • Physiologic: bilateral, multiple ducts, white/green/yellow, provoked 2, 3
    • Pathologic: spontaneous, unilateral, single duct, serous or bloody 3
• Ask about:
  • Duration of symptoms
  • Associated pain or itching
  • Recent changes in soaps, detergents, or lotions
  • History of atopic conditions (eczema, asthma, allergies)
  • Breastfeeding status
  • Medication use

Physical Examination

• Examine both nipples and areolae for:
  • Scaling pattern (diffuse vs localized)
  • Erythema
  • Fissures or cracks
  • Discharge (if present)
  • Underlying masses
  • Nipple inversion or retraction (new onset)
  • Skin changes beyond the nipple-areolar complex

Diagnostic Pathway

For Dry Flaky Nipples Without Discharge:

1. Consider nipple eczema first - most common cause of dry flaky nipples 1

   • Types: atopic, irritant, or allergic contact eczema
   • May require skin swab or biopsy if diagnosis uncertain

2. Rule out important differential diagnoses:

   • Nipple psoriasis
   • Nipple candidiasis
   • Paget's disease (especially in older patients with unilateral, persistent symptoms) 1, 4

For Dry Flaky Nipples With Discharge:

1. Categorize discharge as physiologic or pathologic 3

2. Imaging based on age and discharge characteristics:

   • For physiologic discharge: No imaging needed if screening mammography is up to date 2, 3
   • For pathologic discharge or if uncertain:
     • Age <30: Ultrasound first 3
     • Age 30-39: Ultrasound first, with mammography if suspicious findings 3
     • Age ≥40: Diagnostic mammography AND ultrasound 2, 3

3. For male patients with nipple discharge: Immediate evaluation with mammography and ultrasound due to high malignancy risk (57%) 2, 3

Management of Nipple Eczema

1. First-line treatment:

   • Topical corticosteroids or calcineurin inhibitors 1
   • Both considered safe during lactation

2. Supportive measures:

   • Avoid irritants (harsh soaps, fragranced products)
   • Moisturize nipples intensively
   • Switch to emollient wash products
   • Warm water compresses or black tea compresses for comfort 1

3. For breastfeeding women:

   • Consider nipple protection devices
   • Adjust latch/suck positioning 1
   • Avoid use of pacifiers and bottles which are associated with sore nipples 5

When to Consider Biopsy

• Unilateral persistent symptoms despite treatment
• Associated nipple retraction or inversion (new onset)
• Suspicious findings on imaging
• Bloody discharge
• Paget-like appearance (crusting, erosion, ulceration)

Important Caveats

• Avoid dismissing male nipple discharge as it carries high malignancy risk (57%) 2, 3
• Avoid overusing mammography in young women (<30 years) 3
• Hydrogel wound dressings should be avoided due to increased infection risk compared to lanolin and breast shells for nipple issues 6
• Nipple discharge is the presenting symptom in 5-12% of breast cancers, requiring careful evaluation 7

By following this structured approach, clinicians can effectively differentiate between benign conditions requiring simple interventions and more concerning presentations that warrant further investigation.