What is the workup for a patient presenting with pruritus (itching) of the breast?

Workup for Itching Breast

A thorough workup for breast pruritus should include a detailed clinical history, physical examination, and targeted investigations to rule out both dermatological conditions and underlying systemic diseases that may present with breast itching.

Clinical Assessment

History

• Ask about breast changes and how they were identified 1:
  • Duration and characteristics of itching (focal vs. general, constant vs. intermittent)
  • Associated symptoms (pain, nipple discharge, skin changes)
  • Screening practices (prior mammograms, clinical breast exams)
  • Personal history of breast disease, surgery, or cancer
  • Hormonal therapy or oral contraceptive use
  • Family history of breast disease

Physical Examination

• Visual inspection 1:

  • Assess symmetry in breast shape or contour
  • Look for skin changes: erythema, retraction, dimpling
  • Examine nipple for changes, particularly eczema-like changes, bleeding, ulceration, excoriation, scaling
  • Check for nipple discharge

• Palpation:

  • Examine both breasts and nearby lymph nodes
  • Identify any masses or areas of tenderness

Diagnostic Workup

Initial Investigations

Based on the British Association of Dermatologists' guidelines 1, initial investigations for generalized pruritus should include:

1. Laboratory tests:

   • Complete blood count and ferritin levels (to rule out iron deficiency)
   • Liver function tests (to assess for cholestasis or liver disease)
   • Urea and electrolytes (to evaluate renal function)

2. Imaging:

   • Bilateral diagnostic mammogram for women ≥30 years
   • Ultrasound as the first imaging modality for women <30 years 2
   • Consider MRI if initial imaging is negative but clinical suspicion remains high

Specific Considerations for Breast Pruritus

1. Rule out Paget's disease:

   • If nipple or areolar eczema, ulceration, bleeding, or itching is present, consider Paget's disease 2
   • Full-thickness skin biopsy of involved nipple-areolar complex is essential for diagnosis 2
   • Do not delay diagnosis with antibiotics or topical treatments for presumed dermatologic conditions 2

2. Evaluate for malignancy:

   • A thorough history and physical examination should be performed
   • Pruritus with appropriate systemic symptoms of malignancy needs tailored investigations 1
   • Consider skin biopsy if persistent, unexplained pruritus to rule out cutaneous lymphoma 1

3. Consider post-surgical factors:

   • In patients with history of breast surgery or reconstruction, consider "post-reconstruction dermatitis of the breast" 3
   • This can develop weeks to years following breast reconstruction

Management Approach

Treatment Algorithm

1. If dermatological cause identified:

   • Topical corticosteroids for inflammatory conditions (apply to affected area not more than 3-4 times daily) 4
   • Topical antibiotics if secondary infection is suspected 3

2. If systemic cause identified:

   • Treat the underlying condition (e.g., iron replacement for iron deficiency) 1
   • Consider referral to appropriate specialist based on findings

3. For refractory pruritus:

   • Consider antihistamines
   • In cases associated with malignancy, mirtazapine may provide relief 5
   • Phototherapy (UVB) may be beneficial in some cases 1

Pitfalls to Avoid

• Do not dismiss nipple changes as benign dermatologic conditions without thorough evaluation 2
• Do not rely solely on imaging; biopsy is essential when Paget's disease is suspected 2
• Do not delay diagnosis with antibiotics or topical treatments for presumed dermatologic conditions 2
• Remember that pruritus can be a manifestation of systemic disease, including malignancy 6

Follow-up

• If initial workup is negative but symptoms persist, consider:
  • Repeat examination in 4-6 weeks
  • Referral to dermatology
  • Additional testing based on clinical evolution

By following this systematic approach, clinicians can effectively evaluate and manage patients presenting with breast pruritus, ensuring that serious underlying conditions are not missed.