Diagnostic Workup and Management of Painful Itchy Area Around Breasts
Obtain bilateral diagnostic mammogram with or without ultrasound immediately, as any unusual skin changes around the breast may represent serious disease including Paget's disease or inflammatory breast cancer, which require urgent evaluation. 1, 2
Immediate Diagnostic Approach
The first step is imaging, not empiric treatment. 1, 2 The National Comprehensive Cancer Network mandates bilateral diagnostic mammography with or without ultrasound as the initial evaluation for any breast skin changes, regardless of how benign they appear clinically. 1, 2
Critical differential diagnoses to consider:
- Paget's disease of the breast - presents with nipple/areolar eczema, itching, scaling, and excoriation; frequently occult on mammography, so negative imaging does not exclude it 1, 2, 3
- Inflammatory breast cancer - look for dermal edema (peau d'orange) and erythema involving ≥1/3 of breast skin with palpable border 1, 2
- Nipple eczema (atopic, irritant, or allergic contact dermatitis) - most common benign cause 4, 5
- Mastitis/abscess - look for induration, warmth, fever 1, 6
Management Algorithm Based on Imaging Results
If imaging shows BI-RADS 1-3 (negative/benign/probably benign):
- Perform punch biopsy of affected skin or nipple biopsy to exclude Paget's disease 1, 2
- Do NOT treat empirically with antibiotics or topical steroids before obtaining tissue diagnosis, as this delays diagnosis of malignancy 2
- If biopsy is benign, reassess clinical-pathologic correlation and consider breast MRI or repeat biopsy if suspicion remains 1
If imaging shows BI-RADS 4-5 (suspicious/highly suggestive of malignancy):
- Perform core needle biopsy with or without punch biopsy 1
- If malignant, treat according to breast cancer guidelines immediately 1, 2
Symptomatic Management During Workup
While awaiting diagnostic results, provide symptomatic relief with:
- Over-the-counter NSAIDs (ibuprofen) for pain 2, 7
- Well-fitted supportive bra 8, 7
- Ice packs or heating pads for comfort 8, 7
Reassure the patient that breast pain alone carries only 1.2-6.7% cancer risk, though skin changes elevate concern and mandate full workup. 1, 2
If Diagnosis Confirms Benign Eczema
Once malignancy is excluded by biopsy, treat nipple eczema with:
- Topical corticosteroids (hydrocortisone 1-2.5% applied 3-4 times daily for up to 7 days) as first-line treatment 9, 4
- Topical calcineurin inhibitors as alternative 4
- Intensive moisturization with emollients 4
- Avoid irritants (friction, chemical agents, allergens) 4
- Warm water or black tea compresses for comfort 4
Critical Pitfalls to Avoid
Never dismiss skin changes around the breast without proper imaging and biopsy. 2 Paget's disease is frequently confused with benign dermatologic conditions and diagnosis is often delayed. 1, 3 The condition presents with itching as a common early symptom, and eczematoid changes are typical. 3
Never treat presumptively with topical steroids, antibiotics, or antivirals without obtaining tissue diagnosis first. 2 This can mask malignancy and delay appropriate cancer treatment.
Remember that pure Paget's disease is frequently occult on mammography - a negative mammogram does NOT exclude the diagnosis. 1, 2 Skin biopsy is mandatory when clinical suspicion exists.