What is the diagnosis and treatment for painful vesicles around the areola of both breasts?

Painful Vesicles Around the Areola of Both Breasts

The most likely diagnosis is herpes simplex virus (HSV) infection of the nipple-areolar complex, which requires immediate evaluation with bilateral diagnostic mammogram with or without ultrasound, followed by punch biopsy of the skin lesions to exclude Paget's disease and confirm the infectious etiology. 1

Immediate Diagnostic Workup

Any unusual skin changes around the breast represent potentially serious disease and mandate evaluation. 1

Initial Imaging

• Obtain bilateral diagnostic mammogram with or without ultrasound as the first step, regardless of what the vesicles appear to be clinically 1
• This imaging is mandatory even if the clinical appearance suggests a benign infectious process, because Paget's disease can mimic dermatologic conditions and is frequently occult on mammography 1

Skin Biopsy Protocol

After imaging is completed:

• Perform punch biopsy of the skin or nipple biopsy if imaging shows BI-RADS category 1-3 (negative, benign, or probably benign findings) 1
• Antibiotics may or may not be given depending on clinical suspicion for infection, but should not delay diagnostic evaluation 1
• If imaging shows BI-RADS category 4 or 5 (suspicious or highly suggestive of malignancy), perform core needle biopsy with or without punch biopsy 1

Critical Differential Diagnoses

Paget's Disease of the Breast

• Nipple excoriation, scaling, and eczema should increase clinical suspicion for Paget's disease, which is a rare manifestation of breast cancer characterized by neoplastic cells in the epidermis of the nipple-areolar complex 1
• Most commonly presents with eczema of the nipple or areola, bleeding, ulceration, and itching 1
• The diagnosis is often delayed because of confusion with other dermatologic conditions 1
• Pure Paget's disease is frequently occult on mammography, and a negative mammogram does not exclude Paget's disease 1

Herpes Simplex Virus (HSV)

• Vesicular lesions around the areola are characteristic of HSV infection 2
• Can occur bilaterally and presents with painful vesicles 2
• Requires viral culture or PCR from vesicle fluid for definitive diagnosis 2

Inflammatory Breast Cancer (IBC)

• IBC should be considered when dermal edema (peau d'orange) and breast erythema are present 1
• IBC is a clinical diagnosis requiring erythema and dermal edema of a third or more of the skin of the breast with a palpable border 1
• Accounts for 1-6% of breast cancer cases but is aggressive 1

Management Based on Biopsy Results

If Biopsy Shows Benign Results

• Reassess clinical and pathologic correlation 1
• Consider breast MRI, repeat biopsy, and consultation with a breast specialist 1
• If HSV is confirmed, treat with antiviral therapy (acyclovir or valacyclovir) 2

If Biopsy Shows Malignancy

• Treat according to breast cancer guidelines immediately 1

Pain Management During Workup

While awaiting diagnostic results:

• Over-the-counter NSAIDs for symptomatic relief 3
• Well-fitted supportive bra 3
• Ice packs or heating pads for comfort 3
• Reassurance that breast pain alone rarely indicates cancer (risk 1.2-6.7%), though the presence of skin changes elevates concern 1, 3

Critical Pitfalls to Avoid

• Never dismiss skin changes around the breast without proper imaging and biopsy, as Paget's disease is frequently confused with benign dermatologic conditions 1
• Do not treat presumptively with antibiotics or antivirals without obtaining tissue diagnosis first, as this can delay diagnosis of malignancy 1
• Do not be falsely reassured by negative mammography - proceed with punch biopsy regardless of imaging results when skin changes are present 1
• Avoid treating repeatedly for presumed Candida infection without confirming diagnosis, as this is a common error that delays appropriate diagnosis 4