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A 39 year old woman presented with an asymptomatic ulcer on her left nipple. The ulcer had been present for five weeks. She also reported malaise. She denied any travel history in the past three months, but recalled a history of breast bites and breast-genital contact during sexual intercourse, which had occurred two weeks before the skin lesion appeared. Physical examination revealed demarcated ulceration with a border that was slightly elevated, crusted, and indurated ( fig 1 ). Left axillary lymphadenopathy was noted.
Questions
1. What are the clinical differential diagnoses of nipple ulceration?
2. What investigations would be helpful to confirm the diagnosis?
3. How would you manage the main differentials?
Answers
What are the clinical differential diagnoses of nipple ulceration?
Short answer
The main clinical differential diagnoses ( table 1 ) are Paget's disease of the breast, herpes simplex virus infection, eczema of the nipple, syphilitic chancre (primary syphilis), erosive adenomatosis of the nipple, impetigo, and cutaneous malignant neoplasms.
| Differential diagnoses | Causes and risk factors | Signs and symptoms |
| Paget's disease of the breast 1 | Women after menopause | Early stage: almost always unilateral lesions with itch, burning, or pain Advanced stage: round or ovoid, thickened, eczematoid, crusted erythematous plaques with irregular margins |
| Herpes simplex virus infection 8 | Herpes simplex virus Spread mainly by sexual contact | A group of vesicles on an erythematous base, which then develop to an erosion or a superficial ulcer Commonly heals in 2-6 weeks, but might last longer in immunocompromised individuals Local symptoms include pain, itch, burning, and regional lymphadenopathy There can be systemic symptoms, such as fever, malaise, and headache in patients with primary infection Might be recurrent |
| Eczema 2 3 | Pregnancy or breast feeding Personal or family history of atopy Atopic eczema at other sites of the body | Itching erythematous scaly papules, plaques, exudation, and vesicles Tends to be intermittent in nature |
| Primary syphilis (syphilitic chancre) 9 10 | Treponema pallidum Sexually transmitted | Develops 10-90 days (average 3 weeks) after sexual exposure Typically firm, round, and painless ulcer on the genital area Might occur at extragenital sites (12%-14% in heterosexual couples, and 32%-36% in men who have sex with men), including the lips, oral mucosa, chin, neck, anus, arms, and nipple (oral... |