What are the treatment options for bleeding bumps on the areola?

Bleeding Bumps on Areola: Diagnostic Evaluation and Treatment

Bleeding bumps on the areola require urgent evaluation with bilateral diagnostic mammography and punch biopsy to exclude Paget's disease of the breast, a rare but serious malignancy that presents with bleeding, eczematoid changes, and ulceration of the nipple-areolar complex. 1, 2

Immediate Diagnostic Workup

Initial Imaging

• Obtain bilateral diagnostic mammography with or without ultrasound as the first-line imaging study, regardless of patient age 1, 2
• Ultrasound serves as a valuable adjunct for evaluating the retroareolar region, especially when mammography is negative 3
• Critical pitfall: Paget's disease can be occult on mammography—a negative mammogram does NOT exclude the diagnosis 1

Tissue Diagnosis Based on Imaging Results

If imaging shows BI-RADS 1-3 (negative, benign, or probably benign):

• Proceed directly to punch biopsy of the skin or nipple biopsy 1
• The biopsy must include full thickness of the epidermis and at least a portion of any clinically involved nipple-areolar complex 3
• Do NOT delay biopsy with empiric antibiotics unless there is clear evidence of infection 1

If imaging shows BI-RADS 4-5 (suspicious or highly suggestive of malignancy):

• Perform core needle biopsy with or without punch biopsy as the preferred approach 1
• Surgical excision is an alternative option 1

Why This Matters: Paget's Disease

Paget's disease of the breast is the primary concern and presents with:

• Bleeding, ulceration, eczema-like changes, scaling, or itching of the nipple-areolar complex 1, 2, 4
• 80-90% of cases have associated underlying breast cancer (invasive or in situ) 2
• The diagnosis is often delayed because it mimics benign dermatologic conditions like eczema 1, 4

The most dangerous pitfall is mistaking Paget's disease for benign eczema—if there is any uncertainty, biopsy rather than prolonged topical steroid trials 2

If Biopsy Results Are Benign

• Reassess clinical and pathologic correlation 1
• Consider breast MRI, repeat biopsy, and consultation with a breast specialist 1
• Clinical re-examination with imaging in 3-6 months if findings remain stable 1

If Paget's Disease Is Confirmed

• Obtain breast MRI to define disease extent and identify additional lesions 3
• Refer to breast surgery for definitive management 2
• Treatment typically involves removal of the entire nipple-areolar complex with negative margins 3
• Whole-breast radiation therapy follows breast-conserving surgery 3

Key Clinical Features to Document

• Unilateral versus bilateral involvement (unilateral raises concern for Paget's disease) 2
• Presence of erythema, dermal edema, scaling, or ulceration 1, 2
• Any palpable breast mass or lymphadenopathy 4, 5
• Duration of symptoms (delays in diagnosis are common) 4, 5

Bottom Line

Do not treat bleeding areolar bumps empirically as dermatitis or infection without tissue diagnosis. The combination of bilateral diagnostic mammography and punch biopsy is essential to exclude Paget's disease, which carries significant morbidity and mortality if diagnosis is delayed. 1, 2