What is the appropriate management for a burn-like lesion on the breast?

Management of Burn-Like Lesion on the Breast

A burn-like lesion on the breast requires immediate evaluation to rule out Paget's disease of the breast, which commonly presents with burning sensation and eczematoid changes of the nipple-areola complex, followed by appropriate imaging and biopsy if suspicious features are present. 1

Initial Clinical Assessment

The most critical step is distinguishing between an actual burn injury versus Paget's disease of the breast, which mimics burn-like symptoms:

• Paget's disease characteristically presents with burning sensation, itching, and eczematoid changes of the nipple-areola complex that can progress to ulceration and destruction if left untreated 1
• Any persistent burning, soreness, or itching of the nipple-areola without obvious cause warrants thorough evaluation including mammography 1
• Surgical biopsy is the diagnostic standard and must be performed to confirm or exclude Paget's disease, as negative exfoliative cytology does not exclude the diagnosis 1

Diagnostic Workup for Suspicious Lesions

If the clinical presentation suggests possible malignancy rather than simple thermal injury:

• Complete breast ultrasound with mammogram to characterize the lesion 2
• If imaging shows BI-RADS category 4-5, proceed with core needle biopsy (preferred method) 2
• Ensure concordance between pathology results and imaging findings after biopsy 2
• If biopsy confirms malignancy, refer for treatment according to breast cancer guidelines 2
• If biopsy shows benign findings but is discordant with imaging, surgical excision is necessary 2

Management of Confirmed Thermal Burn Injury

If the lesion is determined to be an actual burn rather than malignancy:

Immediate Treatment (First 6-12 Hours)

• Apply cold therapy immediately through vasoconstriction to limit bleeding and prevent hematoma expansion 3
• Use ice-water mixture in plastic bag or damp cloth with thin barrier between cold pack and skin to prevent frostbite 3
• Apply for 20-30 minutes per application, repeat 3-4 times daily 3
• Heat application is explicitly contraindicated as it increases bleeding and swelling 3
• Add compression during or after cold application for optimal results 3

Wound Care

• For minor burns, clean the affected area and apply topical bacitracin 1-3 times daily (amount equal to fingertip surface area) 4
• May be covered with sterile bandage 4
• Meticulous hemostasis is critically important to prevent hematoma formation, which produces changes difficult to interpret on examination and mammography 5, 3

Surgical Management for Severe Burns

If surgical debridement or excision becomes necessary:

• Remove necrotic tissue completely in one piece rather than multiple fragments to allow proper margin assessment 5
• Use curvilinear skin incisions following Langer's lines for optimal cosmetic results 5
• For lower breast lesions requiring skin excision, radial incisions may provide better cosmesis 6
• Close all breast skin incisions with subcuticular technique to minimize visible scarring 5
• Preserve subcutaneous tissue with separate closure to improve cosmetic outcome 5
• Allow the biopsy cavity to fill with serum rather than reapproximating breast tissue, as reapproximation causes distortion when upright 5

Special Considerations

Lactating Patients

• If burns involve lactating breasts, consider bromocriptine to produce cessation of lactation and breast involution before surgical intervention to prevent complications including engorgement, mastitis, milk fistulae, and glandular loss 7

Pediatric Patients

• Burns to the breast bud in young females may inhibit normal breast development and result in significant asymmetries or amastia 8
• Follow-up for potential reconstructive procedures should be planned, with mean follow-up time of 7.2 years after injury in severe cases 8

Critical Pitfalls to Avoid

• Do not assume a "burn-like" lesion is actually a burn without ruling out Paget's disease, especially if there is persistent itching, burning, or eczematoid changes without clear thermal injury history 1
• Do not delay evaluation of suspicious breast lesions while managing other findings 2
• Do not rely on negative exfoliative cytology to exclude Paget's disease; surgical biopsy is mandatory for definitive diagnosis 1
• Avoid heat application in acute phase of actual burn injuries as it worsens bleeding and swelling 3
• Do not reapproximate breast tissue under tension as this causes distortion when patient is upright 5