Mrs. Jones is a 60 yo F with PMH including BCC on her nose, melanoma on her leg, asthma, seasonal allergies, many food allergies, and eczema. She has had recurrent eczema involving her left nipple for many years. She has been prescribed > 5 courses of high-potency topical steroids, but her eczema has never completely resolved. She presents to clinic today with a "flare" of her eczema. She reports that the skin over her left nipple has been itchy, with new skin color changes from diffusely pink to splotchy deeper red and intermittent bleeding.
Which of the following is the most likely diagnosis?
A-atopic dermatitis
B-melanoma
C-inflammatory breast cancer
D-Paget disease
set up each as a link with answer D correct
D-Paget disease:
Yes, Mrs. Jones most likely has Paget Disease of the nipple. Unlike eczema/atopic dermatitis, Paget will not completely respond to topical steroids. Unlike melanoma, Paget does not cause black or blue/black skin pigmentation (the deep red color in this case is from inflammation, itching, bleeding, ulceration). And in contrast to inflammatory carcinoma, the skin/nipple changes seen in Paget take years, (not months) to evolve
A-Atopic dermatitis
No, while atopic dermatitis is a common diagnosis in people with asthma and allergies, and can cause itchy, thickened, erythematous lesions, atopic dermatitis would respond to topical steroids and would not progress over the nipple/areolar complex over years
B-Melanoma
No, while this patient has a personal history of melanoma and basal cell carcinoma (so we can assume she has had a fair amount of sun exposure), the nipple is not typically sun-exposed. More importantly, although Mrs. Jones reports new skin color changes from diffusely pink to splotchy deeper red, thns is not the classical blue/black of melanoma
C-Inflammatory breast cancer
No, although inflammatory carcinoma can present with a large area of breast erythema, itching, and nipple changes, the hallmark of inflammatory carcinoma is rapid onset of symptoms (over months); not years, as in our patient's case
FAMILY MEDICINE CASE 2