What are the next steps for a patient with persistent right nipple pain and breast pain for two months, now presenting with a new onset of purple discoloration around the nipple?

Urgent Evaluation for Suspected Malignancy

This patient requires immediate diagnostic mammography and ultrasound followed by tissue biopsy if any abnormality is detected, as the combination of persistent pain for two months with new purple discoloration around the nipple represents a suspicious clinical finding that warrants urgent exclusion of inflammatory breast cancer, Paget's disease, or underlying malignancy. 1

Critical Red Flags Present

This presentation contains multiple concerning features that mandate urgent workup:

• Purple/skin discoloration around the nipple is a suspicious skin change that could represent inflammatory breast cancer (which presents with erythema and dermal edema), Paget's disease (which presents with nipple changes including discoloration, scaling, or eczema), or underlying malignancy 1
• Persistent focal pain for two months is noncyclical breast pain, which accounts for 25% of breast pain cases and is more commonly associated with underlying pathology than cyclical pain 1
• New onset of visible skin changes after prolonged symptoms represents clinical progression and elevates concern significantly 1

Immediate Diagnostic Algorithm

Step 1: Obtain Bilateral Diagnostic Mammography ± Ultrasound

• Diagnostic mammography (not screening) is rated 8-9/9 ("usually appropriate") for any patient with suspicious skin changes around the breast or nipple 1
• Ultrasound should be performed as an adjunct to evaluate for any underlying mass or abnormality not visible on mammography 1, 2
• The purple discoloration qualifies as a "suspicious symptom" requiring non-deferrable diagnostic imaging 1

Step 2: Perform Skin/Nipple Biopsy Regardless of Imaging Results

• Punch biopsy of the affected nipple/areolar skin should be performed even if imaging appears normal (BI-RADS 1-3), as Paget's disease is frequently mammographically occult and requires histologic diagnosis 1
• The National Comprehensive Cancer Network states that skin changes around the nipple (including discoloration) require punch biopsy or nipple biopsy after imaging to exclude Paget's disease 1
• Never rely on negative imaging alone when suspicious clinical findings are present—up to 10-15% of breast cancers can be mammographically occult 2

Step 3: Management Based on Combined Clinical and Imaging Findings

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

• Perform core needle biopsy of any identified mass or abnormality immediately (rated 9/9 "usually appropriate") 1, 2
• Proceed with punch biopsy of the discolored skin simultaneously 1

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

• Still proceed with punch biopsy of the discolored nipple/areolar skin, as this is mandatory to exclude Paget's disease which can present with normal mammography 1
• If skin biopsy returns benign, reassess clinical-pathologic correlation and strongly consider breast MRI and consultation with a breast specialist 1
• Clinical reexamination with repeat imaging in 3-6 months if initial biopsy is benign but clinical suspicion remains 1

Key Differential Diagnoses to Exclude

Paget's Disease of the Nipple

• Presents with nipple/areolar changes including discoloration, eczema, scaling, bleeding, or ulceration 1, 3
• Frequently associated with underlying ductal carcinoma in situ or invasive carcinoma 3
• Diagnosis requires skin biopsy—negative mammography does not exclude Paget's disease 1, 3

Inflammatory Breast Cancer

• Presents with erythema, dermal edema (peau d'orange), and breast tenderness affecting at least one-third of the breast 1
• Purple discoloration could represent early inflammatory changes 1
• Requires immediate diagnostic imaging and biopsy 1

Duct Ectasia with Periductal Inflammation

• Accounts for 25% of noncyclical breast pain cases 1
• Characterized by continuous burning pain behind the nipple with breast hypersensitivity 1
• Often associated with heavy smoking 1
• May show duct ectasia or secretory calcifications on mammography at the site of pain 1

Zuska's Disease (Subareolar Abscess)

• Can present with nipple redness, pain, and discharge from the areolar margin 4
• Requires surgical treatment with microdochectomy 4

Critical Pitfalls to Avoid

• Do not dismiss this as simple mastalgia—the presence of visible skin changes (purple discoloration) fundamentally changes the risk assessment and mandates urgent workup 1
• Do not delay biopsy based on negative imaging—Paget's disease and some breast cancers are mammographically occult and require tissue diagnosis 1, 3
• Do not treat empirically with antibiotics without obtaining tissue diagnosis first, as this can delay diagnosis of malignancy 1
• Do not attribute symptoms to benign causes (dermatitis, infection) without histologic confirmation when suspicious clinical features are present 1

Timeline for Action

This patient requires urgent (non-deferrable) evaluation within days, not weeks 1:

• Diagnostic imaging should be scheduled immediately 1
• Skin biopsy should be performed within the same week as imaging 1
• If biopsy shows malignancy, immediate referral to breast surgical oncology per NCCN Breast Cancer Guidelines 1