Paget's disease of the nipple

An eczema-like rash on the nipple that is usually a sign of breast cancer underneath. Treated as eczema for months is the common story.

What it is

A rare form of breast cancer affecting the nipple and areola, appearing as a red, scaly, itchy rash.

It accounts for a small percentage of breast cancers, and in the great majority of cases there is an underlying cancer within the breast, either invasive or in situ, even when no lump can be felt.

**The problem is that it looks exactly like eczema.** People are given steroid cream, the rash partly improves, and months pass. The distinguishing features are that it starts on the nipple and spreads outwards onto the areola, rather than the reverse; it is usually one-sided; and it does not resolve properly with steroid treatment.

Eczema of the breast, by contrast, usually affects both sides, tends to spare the nipple itself, and responds to treatment.

The rule that prevents delay is straightforward: **a persistent one-sided nipple rash that has not cleared after a couple of weeks of treatment needs urgent breast clinic referral and a punch biopsy of the nipple skin**, not another prescription.

It can occur in men, where nipple changes are even more likely to be dismissed.

Treatment depends on what is found underneath, and mammography can be normal, so a normal mammogram does not exclude it.

Signs you might notice

A red, scaly, crusted or weeping rash on the nipple, spreading onto the areola.

Itching, burning or tingling.

Usually one-sided.

Nipple flattening or inversion.

Discharge from the nipple, sometimes blood-stained.

An ulcer that does not heal.

Sometimes a lump, though often none.

**Urgent breast clinic referral for any persistent one-sided nipple rash**, particularly one that has not cleared with two weeks of treatment.

Also urgent: nipple inversion that is new, blood-stained discharge, a lump, or skin dimpling.

In men: any nipple or areolar rash, discharge or lump.

How it can affect day-to-day life

The delay is almost always caused by the eczema assumption on both sides: the person assumes it is a rash, and the first clinician treats it as one.

Asking two questions changes it: is it one-sided, and has it cleared with treatment. A one-sided persistent rash is not eczema until proven otherwise.

A normal mammogram is reassuring about a lump and does not exclude this, because the disease is in the nipple skin. The diagnosis is made on biopsy.

Nipple biopsy is a small procedure under local anaesthetic and is quick.

Treatment historically meant mastectomy in all cases; now, where the underlying disease is limited, breast-conserving surgery with removal of the nipple and areola plus radiotherapy is often possible, and reconstruction including nipple tattooing gives good results.

Men diagnosed with breast disease face particular isolation, since services and support materials are overwhelmingly aimed at women.

Supporting someone well

Ask two questions: is it one-sided, and has it cleared with treatment.

Do not accept repeated steroid creams for a persistent one-sided nipple rash.

Ask for urgent breast clinic referral and a nipple biopsy.

Understand that a normal mammogram does not exclude it.

Get any new nipple inversion, blood-stained discharge or non-healing ulcer referred urgently.

For men, insist on assessment; nipple changes in men are frequently dismissed.

Ask about breast-conserving options and reconstruction, including nipple tattooing.

Ask for the breast clinical nurse specialist.

Where to get help

A GP practice for urgent breast clinic referral.

The breast clinic for biopsy and treatment.

Breast Cancer Now on 0808 800 6000, who support men as well as women.

Macmillan Cancer Support on 0808 808 00 00.