Evaluation of Resolved Itchy Nipple

Introduction to Paget's Disease

The National Comprehensive Cancer Network (NCCN) guidelines state that nipple itching can be a presenting symptom of Paget's disease, which is often misdiagnosed as benign dermatologic conditions 1, 2
Paget's disease presents with nipple itching in many cases and diagnosis is frequently delayed due to confusion with benign conditions, with the NCCN guidelines emphasizing that "nipple excoriation, scaling, and eczema should increase clinical suspicion of Paget's disease" 1, 2

An underlying breast cancer is present in 80-90% of Paget's disease cases, which may be either ductal carcinoma in situ (DCIS) or invasive carcinoma 3
Pure Paget's disease is frequently occult on mammography, meaning a negative mammogram does not exclude the diagnosis 1, 2

The NCCN guidelines recommend bilateral diagnostic mammogram with or without ultrasound as the initial imaging study, along with a thorough clinical breast examination looking for any masses, skin changes, or persistent nipple abnormalities 1, 2
If imaging shows BI-RADS 1-3 (negative/benign/probably benign), punch biopsy of the nipple should still be performed if there is clinical suspicion, as normal imaging does not exclude Paget's disease 1, 2
If biopsy is benign but clinical suspicion remains, consider breast MRI, repeat biopsy, and consultation with a breast specialist 1, 2

The American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN) emphasize that symptom resolution does not exclude underlying malignancy, as Paget's disease can have a waxing and waning course 1, 2
Even if symptoms have resolved, the patient had a prolonged symptomatic period that meets criteria for evaluation 1, 2