What are the recommended topical therapies for extramammary mastodynia in an elderly male with cardiovascular pathology?

Topical Therapies for Extramammary Mastodynia in Elderly Male with Cardiovascular Pathology

Topical diclofenac is the recommended first-line topical therapy for extramammary mastodynia in elderly males with cardiovascular pathology, but should be used with caution and for short duration due to potential cardiovascular risks. 1, 2

Understanding Extramammary Mastodynia

Extramammary mastodynia refers to breast-area pain that originates from non-breast tissue sources, such as:

• Chest wall pain
• Costochondral junction inflammation
• Tietze's syndrome
• Musculoskeletal causes

In elderly males, this condition is often related to musculoskeletal issues rather than hormonal factors that commonly affect females 3.

Treatment Algorithm for Elderly Males with Cardiovascular Pathology

First-line Topical Therapy:

1. Topical diclofenac - Apply to affected area 3-4 times daily 1, 2
   • Advantages: Minimal systemic absorption compared to oral NSAIDs
   • Caution: Even topical NSAIDs carry cardiovascular risks, though lower than oral formulations

Second-line Options:

1. Topical capsaicin - Though conditionally not recommended for knee OA 1, it may be considered for chest wall pain when other options fail

   • Start with low concentration (0.025%) and monitor for skin irritation
   • Apply 3-4 times daily

2. Topical lidocaine patches (5%)

   • Apply to painful area for 12 hours daily
   • Remove for 12 hours to prevent skin irritation

Special Considerations for Cardiovascular Pathology

The American Heart Association and American Geriatrics Society emphasize several important considerations when using topical analgesics in elderly patients with cardiovascular disease 1:

1. Cardiovascular Risk Assessment:

   • Even topical NSAIDs like diclofenac can increase risk of:
     • Myocardial infarction
     • Stroke
     • Heart failure exacerbation
     • Hypertension
     • Renal dysfunction

2. Monitoring Requirements:

   • Blood pressure should be monitored regularly during treatment
   • Renal function should be assessed periodically
   • Watch for signs of heart failure exacerbation (edema, shortness of breath)

3. Duration Limitations:

   • Use for the shortest duration possible (<4 weeks ideally) 1
   • Intermittent rather than continuous use is preferred

Important Precautions and Contraindications

Absolute Contraindications for Topical NSAIDs:

• Recent myocardial infarction or stroke
• Decompensated heart failure
• Severe renal dysfunction
• Known hypersensitivity to NSAIDs
• Aspirin-sensitive asthma 2

Relative Contraindications:

• Stable coronary artery disease
• Controlled hypertension
• Mild-to-moderate renal impairment

Avoiding Common Pitfalls

1. Do not use with oral NSAIDs concurrently - This increases risk of adverse effects without additional benefit 2

2. Avoid sun exposure to treated areas - Topical diclofenac can increase photosensitivity 2

3. Prevent eye contact with topical preparations 2

4. Monitor for skin reactions - Discontinue immediately if rash or irritation develops 2

5. Be aware of drug interactions - Particularly with:

   • Anticoagulants (increased bleeding risk)
   • Antihypertensives (reduced efficacy)
   • Diuretics (reduced efficacy) 1, 2

Alternative Approaches

If topical therapies are ineffective or contraindicated, consider:

1. Scheduled acetaminophen - Up to 3000mg daily (reduced from standard 4000mg due to age and cardiovascular risk) 1, 4

   • Administer on a scheduled basis rather than as needed
   • Monitor for hepatotoxicity

2. Physical therapy modalities:

   • Gentle stretching exercises
   • Local heat application
   • Transcutaneous electrical nerve stimulation (TENS)

3. For refractory cases, consider referral to pain specialist for evaluation of other interventional options 1

By following this approach, you can effectively manage extramammary mastodynia in elderly males with cardiovascular pathology while minimizing risks associated with treatment.