What is the best course of action for a patient experiencing chronic itching in the right nipple for several months?

Chronic Unilateral Nipple Itching: Evaluation and Management

For chronic itching isolated to one nipple lasting several months, you must first exclude Paget's disease of the breast through skin biopsy, as this presentation is a red flag for underlying malignancy that requires urgent diagnosis. 1

Immediate Diagnostic Priority

Rule Out Malignancy First

• Unilateral nipple symptoms warrant heightened suspicion for Paget's disease, particularly when itching persists for months without clear dermatologic cause 1
• Perform a skin biopsy of the affected nipple if there is any scaling, crusting, erosion, or persistent symptoms despite initial treatment 1
• Clinical examination should specifically assess for nipple changes including erythema, scaling, eczematous appearance, or any discharge 1, 2

Key Differential Diagnoses to Consider

• Nipple eczema (atopic, irritant, or allergic contact dermatitis) - most common benign cause 1
• Paget's disease - malignant condition that can mimic eczema 1
• Nipple psoriasis - typically bilateral but can be unilateral 1
• Nipple candidiasis - consider if risk factors present 1

Diagnostic Workup

Clinical Assessment

• Document exact location, duration, quality of itch, and any associated skin changes 3, 4
• Identify potential triggers: new bras, detergents, topical products, friction from clothing or exercise 1
• Examine for primary lesions (erythema, scaling, vesicles) versus secondary changes from scratching 3, 4
• Assess both nipples comparatively, even if symptoms are unilateral 1

When to Biopsy

• Any diagnostic uncertainty between eczema and Paget's disease 1
• Unilateral symptoms persisting beyond 2-4 weeks of appropriate topical therapy 1
• Presence of erosions, ulceration, or bloody discharge 1

Additional Testing if Indicated

• Swab for bacterial or fungal culture if infection suspected 1
• Patch testing if allergic contact dermatitis suspected 1

Treatment Algorithm

First-Line Therapy (After Excluding Malignancy)

• Topical corticosteroids: Start with mid-to-high potency such as triamcinolone 0.1% applied twice daily 1, 5
• Alternatively, topical calcineurin inhibitors (tacrolimus or pimecrolimus) are safe and effective, particularly for sensitive nipple skin 1, 5
• Intensive emollient use after bathing and throughout the day 1, 6

Adjunctive Measures

• Eliminate irritants: Switch to fragrance-free detergents, avoid wool or synthetic fabrics against skin 1
• Warm water or black tea compresses can provide symptomatic relief 1
• For persistent pruritus, consider topical menthol or pramoxine preparations 5, 7
• Advise using emollient wash products instead of soap 1

If No Response After 2-4 Weeks

• Reassess diagnosis - consider biopsy if not already performed 1
• Evaluate for neuropathic component and consider gabapentin 300-900 mg daily if neuropathic pruritus suspected 5, 8
• Consider oral antihistamines (fexofenadine 180 mg or loratadine 10 mg daily) though less effective for localized pruritus 6, 8

Critical Pitfalls to Avoid

• Never assume unilateral nipple symptoms are benign eczema without excluding Paget's disease, especially if symptoms persist beyond initial treatment 1
• Avoid prolonged empiric treatment without biopsy in cases with diagnostic uncertainty 1
• Do not use hydrocortisone cream in the genital area if vaginal discharge present, though this is less relevant for nipple application 9
• Topical corticosteroids and calcineurin inhibitors are safe during lactation if applicable 1

When to Refer

• Refer to dermatology if biopsy confirms Paget's disease or other concerning pathology 1
• Consider dermatology referral if no improvement after 4 weeks of appropriate topical therapy 7, 1
• Refer to breast surgery if Paget's disease confirmed, as this requires surgical management 1, 2