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
• Cutaneous extension of a mammary carcinoma
• Superficial basal cell carcinoma
• Pagetoid basal cell carcinoma
• Benign intraductal papilloma
• Pagetoid dyskeratosis

Category	Diseases	Etiology	Inherited	Acquired	Clinical manifestations									Para-clinical findings			Associated factors
					Demography	Symptoms					Physical examination
														Lab Findings		Histopathology
						Appearance				Itching	Fever	Tenderness	Other	Eosinophils	Serum IgE
						Single/ Multiple	Rash	Involved areas	Pustule
Skin disorders	Atopic dermatitis	Epidermal barrier dysfunction Immune dysregulation	+	+	Incidence is highest during infancy and early childhood.	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	Nl to ↑ (Eosinophilia)	↑	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	Delayed-type hypersensitivity response Skin inflammation mediated by hapten-specific T cells	–	+	Any	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 to ↑ (Eosinophilia)	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	Activation of the innate immune system by the pro-inflammatory properties of chemicals	–	+	Any, more with occupational exposure	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	Nl	Spongiosis Intraepidermal vesicles or bullae Necrosis of keratinocytes	Cumulative exposure to irritants Negative hypersensitivity tests
	Seborrheic dermatitis	Not known	–	+	Any, onset during the infancy and peak during 3rd-4th decades	Multiple	Cradle cap - yellowish scales on the scalp Patchy or diffuse greasy scaling with or without a yellow-red base Crusts	Scalp, face, trunk, postauricular, diaper area and axilla	+	+	–	–	Infants: Cradle cap (Sclap) - non-inflammatory greasy scales on the scalp Asymptomatic Self resolving	Nl	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
	Psoriasis	Keratinocyte hyperproliferation Dysregulation of the immune system	+	+	Any, 2 peaks of onset 30-39 years and 50-59 years	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	Nl	Epidermal hyperplasia Parakeratosis Neutrophils microabscesses (Munro microabscesses)	Risk factors include Smoking Skin trauma Alcohol abuse Stress Cold weather Vitamin D deficiency
	Lichen simplex chronicus	Secondary to extensive pruritus due to other conditions such as atopic dermatitis, neuropathic pruritus, etc	–	+	Any, peak at 30-50 years of age	Multiple	Lichenified and erythematous, pruritic exudative plaque, and excoriations	Scalp, head, neck, hands, arms, and genitals areas	–	+	–	–	Color of plaque varies from yellow to reddish brown Plaque size can vary between 3X6 cm 6X10 cm areas.	Nl	Nl	Markedly hyperplastic epidermis Irregular hyperkeratosis and parakeratosis Thick granular zone Acanthosis	Risk factors include Emotional stress Dry weather Sweating Sexual dysfunction Sleep disturbances Depression
	Ichthyosis vulgaris	Loss of function mutations in the filaggrin gene (FLG) Autosomal dominant inheritance with incomplete penetrance	+	+	Usually in infancy	Multiple	Xerosis and gray scaling Palmar hyperlinearity Keratosis pilaris	Extensor surfaces of the extremities Scalp Trunk	–	–	–	–	Scales can vary from mild scaling to large, plate (armor)-like scales and thickening of the skin.	Nl	Nl	Reduced keratohyalin granules Perinuclear keratin retractions in granular cells Thick stratum corneum Basket-weave pattern of stratum corneum	Increased risk of atopic diseases including asthma, alllergic rhinitis and atopic dermatitis
	Nummular dermatitis (discoid eczema)	Unknown	–	+	Any, two peaks, 6th-7th decade of life in males and 2nd-3rd decade of life in females	Multiple	Symmetrical coin-shaped erythematous plaques Erosions and excoriations Chronic lesions- central clearing leading to annular lesions	Upper and lower extremities Lower trunk	–	+	–	–	Chronically lesions result into central clearing leading to annular lesions.	Nl	Nl	Spongiosis Perivascular lymphocytic infiltrates, with eosinophils and occasional neutrophils	Risk factors include Temperature changes (particularly winter) Emotional stress Dry skin Environmental irritants Recent surgery Medications like topical antibiotic creams and isotretinoin Superinfection with staphylococcus aureus
	Netherton's syndrome	Autosomal recessive mutations in the serine protease inhibitor of Kazal type 5 gene (SPINK5), encoding LEKTI, a serine protease inhibitor	+	–	Affects neonates	Multiple	Classic triad Congenital ichthyosiform erythroderma Trichorrhexis invaginata Allergic diseases with ↑ serum IgE levels Ichthyosis linearis circumflexa (ILC) - serpiginous plaques with double scale at the margins	Diffuse pattern Axillae, Hair Inguinal folds Gluteal cleft Groin Lower legs	+	+	–	–	Trichorrhexis invaginata (hair involvement): Sparse, short, spike and brittle "Bamboo hair" or "ball and socket deformity" of hair and eyebrows Nodes along the hair shaft	Nl to ↑ (Eosinophilia)	↑	Psoriasiform hyperplasia Reduced granular layer Dyskeratosis Dermal inflammatory infiltrate including neutrophils and eosinophils	Atopic diseases including asthma, atopic dermatitis and allergic rhinitis Systemic and skin superinfections Failure to thrive Electrolyte imbalances, including hypernatremia,dehydration
	Diseases	Etiology	Inherited	Acquired	Demography	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Fever	Tenderness	Other	WBC	Serum IgE	Histopathology	Associated factors
Infection	Molluscum contagiosum	Molluscum contagiosum virus inoculation through direct skin contact	–	+	Any, peak among children >5 years of age and young adults	Multiple	Flesh-colored, dome-shaped papules with a central umbilication Lesions are 2-5mm in diameter	Face, trunk, antecubital, popliteal fossae and groin	–	+	–	–	If molluscum contagiosum is acquired as sexually transmitted disease, it involves, groin and genital region.	Nl	Nl	Keratinocytes containing eosinophilic inclusion bodies (Henderson-Paterson bodies) H&E stain - inwards indentation of the epidermis	Often asymptomatic Self resolve within 2 months Immunodeficient patients present with extensive and severe infections Molluscum contagiosum lesions on the eyelid may lead to follicular or papillary conjunctivitis
Immunologic disorders	Dermatitis herpetiformis	Autoimmune disorder as a result of gluten sensitivity leading to the formation of IgA antibodies	–	+	Any, mean age of disease onset is 2nd-4th decade	Multiple	Excoriated papules, plaques and vesicles arranged in a clustered fashion Symmetrical Erosions and excoriations	Extensor surfaces including arms, knees, and buttocks.	–	+	–	–	Oral manifestation such as vesicles and erosion may be present	Nl	Nl	Papillary micro-abscesses Sub-epidermal blisters containing neutrophils, eosinophils, and fibrin Sub-epidermal vacuolization	Intermittent pruritic papules and vesicles Celiac disease with villous atrophy and crypt hyperplasia Abdominal bloating, pain, diarrhea, or constipation
Immune deficiency	Wiskott-Aldrich syndrome	Mutation in the gene encoding for Wiskott-Aldrich syndrome protein (WASp) on the short arm of the X chromosome X-linked disorder	+	–	Seen almost exclusively in males in infancy	Multiple	Rash is clinically similar to atopic dermatitis Erythematous and pruritic lesions Lesions can bleed due to thrombocytopenia Cutaneous manifestations includes petechiae and ecchymosis	Rash can involve lesions located at the same areas of classical atopic dermatitis: extensor surfaces of extremities and cheeks or scalp	–	+	–	–	Infants can present with petechiae, prolonged bleeding from umbilicus or circumcision, purpura,hematemesis, melena, epistaxis, hematuria or unusal bruising	Nl to ↑ (Eosinophilia)	↑	Hyperkeratosis Psoriasiform hyperplasia Dyskeratosis Epidermal psoriasiform hyperplasia Marked intercellular edema with spongiotic vesiculation	↑ serum IgA levels ↑ serum IgE levels Bleeding: severe thrombocytopenia, Eczema - similar to atopic dermatitis Recurrent sino-pulmonary infections Opportunistic infections. Autoimmune diseases Malignancies
	Hyper-IgE syndrome	Defects in the JAK-STAT signaling pathway leading to dysfunctional T helper cell type 17 (Th17) differentiation	+	–	Rare, begin in infancy	Multiple	Papulopustular Severely pruritic eczematous rash Pustular and may impetiginized Lichenification may occur	Face and scalp Upper trunk and shoulders Buttocks Area behind the ears and around the hairline	+	+	–	–	Characteristic coarse facies Increased alar width and broad nasal bridge High-arched oral palate Hyperextensible joints	Nl to ↑ (Eosinophilia)	↑	Eosinophil-rich infiltration around the hair follicles	Cold abscesses Pruritic eczema Allergic diseases Noneruption of permanent teeth Multiple bone fractures and scoliosisis Peripheral T-cell lymphoma Coronary artery aneurysms
Malignancy	Mycosis fungoides	Clonal expansion of CD4+ memory T cells (CD45RO+)	–	+	Mean age is 55- 60 years	Multiple	Non-pruritic patches and intensely pruritic plaques Comedones, cysts Tumors of skin Erythematous macules Hypopigmented patches	Asymmetrical Hips, groin and trunk	–	+	–	–	Alopecia Acneiform lesions Plaques size can vary between 2-20 cm Lymphadenopathy Children- hypopigmented patches most common	Nl	Nl	Perifollicular infiltrates around the infundibulum Epidermis is spared or has minimal spongiosis Band-like dermal infiltrate of lymphocytes and and histiocytes	Increased risk of : Severe viral and bacterial infections Secondary malignancies, especially lymphomas Staging of Mycosis fungoides is based upon: Patches Plaques Skin tumors Lymphadenopathy Erythroderma Histology
Category	Diseases	Etiology	Inherited	Acquired	Demography	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Fever	Tenderness	Other	WBC	Serum IgE	Histopathology	Associated factors