7 Key Symptoms of Paget’s Disease of the Breast You Should Know

Paget’s disease of the breast is a rare type of cancer affecting the nipple and the surrounding areola. Accounting for approximately 1-4% of all breast cancer cases, this condition often mimics benign skin conditions like eczema or dermatitis, which can lead to delayed diagnosis. Understanding the distinctive symptoms of Paget’s disease of the breast is crucial for early detection and timely medical intervention.

This condition typically affects one breast and is almost always associated with underlying breast cancer, either ductal carcinoma in situ (DCIS) or invasive breast cancer. Women over 50 are most commonly affected, though it can occur at any age. Recognizing the warning signs early can significantly impact treatment outcomes and prognosis.

1. Persistent Redness and Flaky Skin on the Nipple

One of the earliest and most common symptoms of Paget’s disease of the breast is the appearance of red, scaly, or flaky patches on the nipple and areola. This symptom often begins subtly and may be mistaken for dry skin or a mild skin irritation.

The affected area typically shows:

• Crusty or scaly patches that resemble eczema or psoriasis
• Redness and inflammation that doesn’t improve with moisturizers or topical treatments
• Peeling or flaking skin that may come and go initially but becomes persistent over time
• Thickened skin around the nipple area that feels rough to the touch

Unlike typical dermatitis, these skin changes in Paget’s disease don’t respond to conventional skin treatments and tend to worsen progressively. The flaky appearance may be accompanied by oozing or crusting, creating a distinctive textured surface on the nipple.

2. Itching, Tingling, or Burning Sensation

Many women with Paget’s disease of the breast experience uncomfortable sensations in the nipple and areola region. These sensations can range from mild to severe and often persist despite attempts to relieve them.

Common sensory symptoms include:

• Persistent itching that may be intense and doesn’t respond to anti-itch creams
• Tingling or pins-and-needles sensation in the nipple area
• Burning feeling that may worsen with clothing friction or temperature changes
• Increased sensitivity making the area tender to touch

These sensations are caused by cancer cells invading the skin of the nipple and affecting nerve endings. The discomfort may be constant or intermittent, and many women report that it interferes with their daily activities and sleep. The itching can be so severe that scratching leads to further skin damage and potential secondary infections.

3. Nipple Discharge

Unusual discharge from the nipple is a significant warning sign of Paget’s disease of the breast. This symptom occurs in approximately 50% of cases and should never be ignored, especially when it occurs spontaneously without squeezing the nipple.

Characteristics of nipple discharge in Paget’s disease include:

• Bloody or blood-tinged discharge ranging from bright red to dark brown
• Yellow or straw-colored fluid that may stain clothing or bras
• Clear or milky discharge in some cases
• Spontaneous leakage occurring without pressure or manipulation
• Discharge from a single duct rather than multiple openings

The discharge may be accompanied by crusting around the nipple opening, and the amount can vary from barely noticeable to requiring padding or breast pads. Any persistent nipple discharge, particularly if bloody or occurring in only one breast, warrants immediate medical evaluation.

4. Inverted or Flattened Nipple

Changes in the shape and position of the nipple are characteristic symptoms of Paget’s disease of the breast. As the condition progresses, the structural integrity of the nipple may be compromised, leading to visible alterations in its appearance.

Nipple changes may include:

• Nipple retraction where the nipple pulls inward into the breast
• Flattening where the nipple loses its natural projection
• Asymmetry when compared to the other breast
• Loss of normal texture and suppleness of the nipple tissue
• Fixed positioning where the nipple no longer responds to temperature or stimulation

These structural changes occur because cancer cells infiltrate and destroy the normal nipple architecture. The inversion typically develops gradually over weeks or months, though in some cases it may occur suddenly. This symptom is particularly concerning if you’ve never had an inverted nipple before or if a previously normal nipple suddenly changes position.

5. A Lump or Mass in the Breast

While Paget’s disease initially manifests as nipple and areola changes, most cases are associated with an underlying breast cancer. As a result, many women also develop a palpable lump or thickening in the breast tissue beneath the affected nipple.

Breast lump characteristics include:

• Hard, irregular mass that feels different from surrounding breast tissue
• Non-mobile lump that doesn’t move freely when pushed
• Location typically behind or near the nipple-areola complex
• Size ranging from very small to several centimeters in diameter
• Painless in most cases, though some women report tenderness

It’s important to note that in approximately 50% of Paget’s disease cases, an underlying invasive breast cancer is present. In another 30-40% of cases, ductal carcinoma in situ (DCIS) is found. Regular breast self-examinations and being familiar with your normal breast tissue can help you detect these changes early. Any new lump, regardless of size or associated symptoms, should be evaluated by a healthcare professional promptly.

6. Thickening or Changes in Breast Skin

Beyond the nipple and areola, Paget’s disease of the breast can cause noticeable changes to the skin of the broader breast area. These changes often indicate that the cancer is affecting a larger portion of the breast tissue.

Skin changes to watch for include:

• Skin thickening that makes the breast feel firmer or harder than normal
• Peau d’orange appearance where the skin resembles orange peel texture due to lymphatic blockage
• Redness or discoloration extending beyond the areola to the breast skin
• Warmth in the affected area that’s noticeable to touch
• Dimpling or puckering of the breast skin when raising your arms
• Enlarged pores on the breast skin

These skin changes occur when cancer cells block lymphatic vessels in the skin or when the tumor pulls on the skin from beneath. The texture changes may be subtle initially but tend to become more pronounced as the condition progresses. The affected breast may also feel heavier or appear slightly larger than the unaffected breast due to fluid accumulation.

7. Persistent Symptoms That Don’t Respond to Treatment

Perhaps one of the most critical distinguishing features of Paget’s disease of the breast is the persistent nature of symptoms despite conventional treatment attempts. Many women initially treat their symptoms as eczema or dermatitis, only to find that standard topical treatments provide no relief.

Key characteristics of this symptom include:

• No improvement with steroid creams or moisturizers typically used for skin conditions
• Symptoms lasting longer than 3-4 weeks without improvement
• Progressive worsening despite treatment attempts
• Recurrence of symptoms immediately after stopping treatment
• Unilateral presentation affecting only one breast (eczema typically affects both)

Healthcare providers should maintain a high index of suspicion for Paget’s disease when nipple eczema doesn’t respond to appropriate dermatological treatment within 2-3 weeks. This treatment resistance is a red flag that should prompt further investigation, including possible biopsy. If you’ve been treating what you believe is a skin condition on your nipple without success, it’s essential to seek medical evaluation to rule out Paget’s disease.

What Causes Paget’s Disease of the Breast?

While the exact mechanism behind Paget’s disease of the breast isn’t completely understood, researchers have identified several key factors and theories about its development:

Underlying Breast Cancer: Paget’s disease of the breast is almost always associated with an existing breast cancer. In most cases, cancer cells from a tumor deeper in the breast migrate through the milk ducts to the nipple and areola skin. This is the most widely accepted theory explaining how Paget’s disease develops.

Primary Development Theory: Some researchers believe that in rare cases, Paget’s disease cells may develop independently in the nipple without an underlying tumor. However, this theory is less commonly supported, as most cases show evidence of deeper breast cancer upon thorough examination.

Types of Associated Cancers:

• Ductal Carcinoma In Situ (DCIS): Found in 30-40% of Paget’s disease cases, this is a non-invasive cancer confined to the milk ducts
• Invasive Ductal Carcinoma: Present in 50-60% of cases, this cancer has spread beyond the milk ducts into surrounding breast tissue
• Invasive Lobular Carcinoma: Less common but can also be associated with Paget’s disease

Risk Factors: While anyone can develop Paget’s disease of the breast, certain factors may increase risk, including:

• Age over 50 (though it can occur at any age)
• Being female (extremely rare in men but possible)
• Having the same risk factors as other breast cancers, including family history, genetic mutations (BRCA1, BRCA2), and hormonal factors
• Previous breast cancer diagnosis

Understanding that Paget’s disease is a manifestation of breast cancer rather than a simple skin condition emphasizes the importance of proper medical evaluation and diagnosis when symptoms appear.

Frequently Asked Questions

How is Paget’s disease of the breast different from regular eczema?

Paget’s disease of the breast typically affects only one nipple, doesn’t improve with standard eczema treatments, and progressively worsens over time. Eczema usually affects both nipples, responds to topical steroids, and may come and go. Additionally, Paget’s disease may be accompanied by a breast lump or bloody discharge, which is not characteristic of eczema.

Can Paget’s disease of the breast occur in men?

Yes, though extremely rare, men can develop Paget’s disease of the breast. It accounts for an even smaller percentage of male breast cancer cases. Men should also be alert to persistent nipple changes, redness, or discharge and seek medical evaluation promptly.

How quickly does Paget’s disease of the breast progress?

The progression rate varies among individuals. Some people may notice gradual changes over several months, while others may experience more rapid symptom development. On average, many people experience symptoms for several months before seeking medical attention, often because they initially mistake it for a benign skin condition.

Is Paget’s disease of the breast always cancer?

Yes, Paget’s disease of the breast is always a form of breast cancer. It involves cancer cells in the nipple and areola skin and is almost always associated with either ductal carcinoma in situ (DCIS) or invasive breast cancer in the underlying breast tissue.

Can Paget’s disease be detected on a mammogram?

Mammograms may not always detect Paget’s disease, especially if there’s no underlying mass. In some cases, the only sign is nipple and areola changes visible on physical examination. This is why clinical breast examination and biopsy of suspicious nipple changes are crucial. If Paget’s disease is suspected, additional imaging such as ultrasound or MRI may be recommended along with a nipple biopsy for definitive diagnosis.

What should I do if I notice symptoms of Paget’s disease?

If you notice any persistent changes to your nipple or areola, especially redness, scaling, itching that doesn’t improve after 2-3 weeks, or any nipple discharge, schedule an appointment with your healthcare provider immediately. Don’t wait to see if symptoms resolve on their own. Early detection significantly improves treatment outcomes. Your doctor will perform a physical examination and may order imaging tests and a biopsy to confirm the diagnosis.

Are there any screening tests specifically for Paget’s disease of the breast?

There are no specific screening tests solely for Paget’s disease. However, regular mammograms and clinical breast examinations as part of routine breast cancer screening can help detect abnormalities. The most important screening method is self-awareness—being familiar with how your breasts normally look and feel so you can detect any changes early. Monthly breast self-examinations can help you identify unusual changes in the nipple or breast tissue.

References:

• American Cancer Society – Paget’s Disease of the Breast
• Mayo Clinic – Paget’s Disease of the Breast
• National Cancer Institute – Paget Disease of the Breast
• Breastcancer.org – Paget’s Disease of the Nipple
• NHS – Paget’s Disease of the Breast