Does a patient with a resolved itchy nipple (pruritus of the nipple) of 1.5 months duration require a medical workup, regardless of symptom resolution?

Workup for Resolved Itchy Nipple After 1.5 Months

Yes, this patient requires evaluation with bilateral diagnostic mammogram and clinical breast examination, even though symptoms have resolved, because nipple itching can be a presenting symptom of Paget's disease of the breast, which is often misdiagnosed as benign dermatologic conditions. 1

Why Evaluation is Still Necessary

Paget's disease presents with nipple itching in many cases and diagnosis is frequently delayed due to confusion with benign conditions. The NCCN guidelines specifically state that "nipple excoriation, scaling, and eczema should increase clinical suspicion of Paget's disease" and that "itching of the nipple" is a common presentation. 1 Critically, symptom resolution does not exclude underlying malignancy, as Paget's disease can have a waxing and waning course. 2

Key Clinical Concerns

• Paget's disease is characterized by neoplastic cells in the nipple epidermis and presents with eczematoid changes, itching, and burning sensations of the nipple-areola complex 2
• The diagnosis is often delayed because it mimics benign dermatologic conditions like eczema or dermatitis 1, 3
• An underlying breast cancer is present in 80-90% of Paget's disease cases, which may be either DCIS or invasive carcinoma 1
• Pure Paget's disease is frequently occult on mammography, meaning a negative mammogram does not exclude the diagnosis 1

Recommended Evaluation Algorithm

Initial Workup

1. Bilateral diagnostic mammogram with or without ultrasound as the initial imaging study 1
2. Thorough clinical breast examination looking for any masses, skin changes, or persistent nipple abnormalities 1

If Imaging Shows BI-RADS 1-3 (Negative/Benign/Probably Benign)

• Punch biopsy of the nipple should still be performed if there is clinical suspicion, as normal imaging does not exclude Paget's disease 1
• The NCCN guidelines emphasize that "further workup is still needed" even when breast imaging results are normal 1
• If biopsy is benign but clinical suspicion remains, consider breast MRI, repeat biopsy, and consultation with a breast specialist 1

If Imaging Shows BI-RADS 4-5 (Suspicious/Highly Suggestive of Malignancy)

• Core needle biopsy is the preferred option, with or without punch biopsy 1
• Proceed according to findings

Important Clinical Pitfalls

The most critical pitfall is dismissing nipple symptoms as benign eczema without proper evaluation. 2, 4, 3 The literature consistently emphasizes that:

• "Eczematoid changes of the nipple-areola complex and persisting soreness or itching, without obvious reason, is a suspicious symptom for Paget's disease" and requires thorough evaluation including mammography 2
• Symptom duration of 1.5 months qualifies as "persistent" and warrants investigation beyond simple dermatologic treatment 2, 4
• Even if symptoms have resolved, the patient had a prolonged symptomatic period that meets criteria for evaluation 1

When Simple Observation is Appropriate

The only scenario where observation alone is acceptable is for bilateral, non-spontaneous, physiologic nipple discharge in young women with normal screening mammography. 5, 6 However, isolated nipple itching is not discharge and falls under the "skin changes" category requiring evaluation. 1

Clinical Bottom Line

Do not be falsely reassured by symptom resolution. The patient experienced 1.5 months of nipple pruritus, which is a recognized presenting symptom of Paget's disease. 1, 2 Start with bilateral diagnostic mammogram and clinical examination, and maintain a low threshold for nipple biopsy if any clinical abnormality persists or if the patient is at higher risk. 1