Paget's disease of the breast differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

Paget's disease of the breast must be differentiated from atopic dermatitis, eczema, psoriasis, malignant melanoma, Bowen's disease, basal cell carcinoma, and pagetoid dyskeratosis.

Differential Diagnosis

Paget’s disease of the breast must be differentiated from other benign and malignant processes of nipple-areola complex such as:

• Atopic dermatitis
• Chronic contact dermatitis
• Lactiferous duct ectasia
• Chronic eczema
• Psoriasis
• Nipple duct adenoma
• Malignant melanoma
• Bowen’s disease
• Superficial basal cell carcinoma
• Pagetoid basal cell carcinoma
• Benign intraductal papilloma
• Pagetoid dyskeratosis

Category	Diseases	Benign or Malignant	Etiology	Clinical manifestations									Para-clinical findings		Gold Standard	Associated factors
				Symptoms						Physical examination
													Lab Findings	Histopathology
				Appearance					Itching	Mastalgia	Breast Exam	Other	Serum IgE
				Single/ Multiple	Rash	Involved areas	Nipple DIscharge	Erythema
Skin disorders	Atopic dermatitis	Benign	Epidermal barrier dysfunction Immune dysregulation	Multiple	Erythema, exudates, papules,vesicles, scales and crusts Infiltrated erythema, prurigo, scales and crusts	Young children -Scalp, cheeks amd extensor surface Adolescents -flexural areas and buttock-thigh creases Adults - facial involvement and skin flexures		–	+	–		Centrofacial pallor Delayed blanch response Keratosis pilaris Palmar hyperlinearity Pityriasis alba Ichthyosis Infra-auricular and retro-auricular fissuring Nipple eczema White dermographism Perifollicular accentuation	↑	Epidermal psoriasiform hyperplasia Marked intercellular edema with spongiotic vesiculation Hyperkeratosis Psoriasiform hyperplasia Dyskeratosis		Family history of atopic dermatitis or other atopy Personal history of atopy (asthma, allergic rhinitis, food allergy) Active and passive exposure to tobacco
	Allergic contact dermatitis	Benign	Delayed-type hypersensitivity response Skin inflammation mediated by hapten-specific T cells	May be multiple after 1-2 days of exposure	Erythematous well-demarcated papules	Surrounding the area in contact with the offending agent		–	+	+		Stinging and burning Localized swelling Lichenified pruritic plaques	Nl	Eosinophilic spongiosis and microvesicles Exocytosis of eosinophils and lymphocytes Chronic - Hyperkeratosis and parakeratosis		Contact with allergens in the past 1-2 days Positive family history
	Irritant contact dermatitis	Benign	Activation of the innate immune system by the pro-inflammatory properties of chemicals	Usually single immediately after the exposure	Well-demarcated red patch with a glazed surface	Any area in contact with the irritant		–	+	+		Swelling, blistering and scaling of the damaged area Dryness Thicker skin	Nl	Spongiosis Intraepidermal vesicles or bullae Necrosis of keratinocytes		Cumulative exposure to irritants Negative hypersensitivity tests
	Psoriasis	Benign	Keratinocyte hyperproliferation Dysregulation of the immune system	Multiple	Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales	Scalp Trunk Gluteal cleft Extensor surface of elbows and knees		+	+	+		Auspitz's sign (pinpoint bleeding)	Nl	Epidermal hyperplasia Parakeratosis Neutrophils microabscesses (Munro microabscesses)		Risk factors include Smoking Skin trauma Alcohol abuse Stress Cold weather Vitamin D deficiency
	Chronic eczema	Benign			Scalp, face, trunk, postauricular, diaper area and axilla	+		+	–			Nl	Focal parakeratosis and spongiosis in epidermis Psoriasiform hyperplasia Neutrophils at the margins	Risk factors include Stress Cold, dry weather can cause flare ups Superinfection with bacteria and candida Generalized seborrheic erythroderma in immunodeficient patients
	Malignant melanoma
	Bowen’s disease
	Superficial basal cell carcinoma
	Pagetoid basal cell carcinoma
	Benign intraductal papilloma
	Pagetoid dyskeratosis
	Lactiferous duct ectasia	Benign	Common among perimenopausalwomen Usually resolve spontaneously
	Nipple duct adenoma
	Benign Toker cell hyperplasia
	Mastitis	Benign								+
	Mondors disease
	Breast abscess	Benign No increased risk of malignancy							+	±	Breasttenderness Swollen breasttissue			Breast parenchymainflammation: Acute mastitis: Staphylococcus infection Granulomatous mastitis: Tuberculosis or sarcoidosisinfection