Breast / Nipple Skin Changes

 

This guideline applies to women over 18 years.

 

 

• Breast implant-associated anaplastic large cell lymphoma
   
• Previous breast cancer
   
• Significant family history of breast or ovarian cancer
   
• Signs and symptoms suggestive of breast cancer:
  • Unexplained discrete breast or axillary lump, ulceration, skin dimpling, breast distortion.
     
  • Bloody or serous unilateral nipple discharge
     
  • Persistent nipple eczema, ulceration, new breast contour change
     
  • Breast infection or inflammation that fails to respond to antibiotics.
     
  • New asymmetric nodularity persisting after menstruation or for 2-3 weeks.

 

 

 

History:

In addition to usual breast symptom history:

• If implants – ask about unexplained breast enlargement, asymmetry, fluid build-up (see breast implants), whether saline or silicone and whether a PIP implant was used
• Previous breast disease/investigations
• Most recent mammogram (offered to all women aged 50-71yrs every 3 yrs)
• Risk factors – obesity, Ashkenazi Jewish ancestry, chest wall radiation, smoking, excess alcohol
• Family history: breast/ovarian cancer (see Familial Breast and Ovarian Cancer), sarcoma under 45yrs, complicated multiple cancers at a young age, glioma or childhood adrenal carcinomas

 

Diagnosis:

• Paget’s disease of the breast– a scaly, raw, vesicular or ulcerated lesion that begins on the nipple and spreads to the areola. Pain, burning or pruritus may be present before the rash/lesion.

 

• Nipple eczema– distinguished from Paget’s as nipple eczema rarely involves the nipple whereas Paget’s starts at the nipple and spreads outwards.

 

• Other changes suggestive of breast cancer– peau d’orange, skin tethering, contour change

 

Associated features warranting referral:

• Associated breast lump
• Ulceration
• Skin distortion
• Unilateral nipple discharge

 

 

 

If persistent and likely infective send charcoal swab or fungal scrapings depending on aetiology.

 

 

 

Nipple eczema (not Paget’s):

• Emollients and soap substitute e.g. Dermol 500
• Avoid irritants e.g. fabric softener, perfumed soaps and shower gels, scented wet wipes
• Apply steroids depending on severity: (ideally under an adhesive dressing)
  • Mild – Clobetasone (Eumovate) ointment BD for 2-3/52
  • More severe – Mometasone (Elocon) OD for 2-3/52
  • Impetiginised – Betamethasone with clioquinol ointment BD 2-3/52
• If not resolved after 2/52 refer to Symptomatic Breast Clinic (2ww form) or dermatology (if part of generalised skin rash)
• If persistent and still likely infective send charcoal swab or fungal scrapings depending on aetiology.

 

 

 

There is no advice and guidance service for breast surgery but if the skin changes are definite eczema then there is an advice service for dermatology.

 

 

 

2ww criteria: (for skin changes) – see in one-stop clinic including imaging

• Skin changes that suggest breast ca. e.g. skin tethering, contour change, peau d’orange, Paget’s
• 50yrs+ with unilateral nipple inversion, retraction, ulceration, or other changes of concern.

 

 

Symptomatic Breast Clinic criteria (refer using 2ww form, seen in clinic and then imaging may be at a later date) for nipple/breast skin changes:

• Nipple rash with no associated symptoms persisting after 2/52 of treatment.

 

 

 

 

For professionals:

• NHS Royal Cornwall Hospitals – Breast Webinar 2022 [video: 1 hour 17 minutes]
• NICE: Clinical Knowledge Summaries (CKS) – Breast Cancer: Recognition and Referral

 

For patients:

• Breast Cancer Now:
• Breast Lumps and Benign (Not Cancer) Breast Conditions
• Information and Support
• CoppaFeel – Information and Resources

 

 

 

Review date	12 January 2024
Next review date	12 January 2026
Clinical editor	Dr Madeleine Attridge
Contributors	Mr Iain Brown (Consultant Breast surgeon) Miss Polly King (consultant Breast surgeon) Dr Rebecca Osborne (GPwSI Breast)