Breast ulcer
Breast ulcer: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Appearing on the nipple, areola, or the breast itself, an ulcer indicates destruction of the skin and subcutaneous tissue. A breast ulcer is usually a late sign of cancer, appearing well after the confirming diagnosis. Breast ulcers can also result from trauma, infection, or radiation.
History and physical examination
Begin the history by asking when the patient first noticed the ulcer and if it was preceded by other breast changes, such as nodules, edema, or nipple discharge, deviation, or retraction. Does the ulcer seem to be getting better or worse? Does it cause pain or produce drainage? Has she noticed any change in breast shape? Has she had a skin rash? If she has been treating the ulcer at home, find out how.
Review the patient's personal and family history for factors that increase the risk of breast cancer. Ask, for example, about previous cancer, especially of the breast, and mastectomy. Determine whether the patient's mother or sister has had breast cancer. Ask the patient's age at menarche and menopause because more than 30 years of menstrual activity increases the risk of breast cancer. Also ask about pregnancy because nulliparity or birth of a first child after age 30 also increases the risk of breast cancer.
If the patient recently gave birth, ask if she breast-feeds her infant or has recently weaned him. Ask if she's currently taking an oral antibiotic and if she's diabetic. All these factors predispose the patient to Candidainfections.
Inspect the patient's breast, noting any asymmetry or flattening. Look for a rash, scaling, cracking, or red excoriation on the nipples, areola, and inframammary fold. Check especially for skin changes, such as warmth, erythema, or peau d'orange. Palpate the breast for masses, noting any induration beneath the ulcer. Then carefully palpate for tenderness or nodules around the areola and the axillary lymph nodes.
Medical causes
❑ Breast cancer. A breast ulcer that doesn't heal within a month usually indicates cancer. Ulceration along a mastectomy scar may indicate metastatic cancer; a nodule beneath the ulcer may be a late sign of a fulminating tumor. Other signs include a palpable breast nodule, skin dimpling, nipple retraction, bloody or serous nipple discharge, erythema, peau d'orange, and enlarged axillary lymph nodes.
GENDER CUE:A breast ulcer may be the presenting sign of breast cancer in men, who are more apt to miss or dismiss earlier breast changes.
❑ Breast trauma. Tissue destruction with inadequate healing may produce breast ulcers. Associated signs depend on the type of trauma, but may include ecchymosis, lacerations, abrasions, swelling, and hematoma.
❑ Candida albicans infection. Severe Candida infection can cause maceration of breast tissue followed by ulceration. Well-defined, bright-red papular patches — usually with scaly borders — characterize the infection, which can develop in the breast folds. In breast-feeding women, cracked nipples predispose them to infection. Women describe the pain, felt when the infant sucks, as a burning pain that penetrates into the chest wall.
❑ Paget's disease. Bright-red nipple excoriation can extend to the areola and ulcerate. Serous or bloody nipple discharge and extreme nipple itching may accompany ulceration. Symptoms are usually unilateral.
Other causes
❑ Radiation therapy. After treatment, the breasts appear “sunburned.” Subsequently, the skin ulcerates and the surrounding area becomes red and tender.
Special considerations
Because breast ulcers become infected easily, teach the patient how to apply a topical antifungal or antibacterial ointment or cream. Instruct her to keep the ulcer dry to reduce chafing and to wear loose-fitting undergarments. If breast cancer is suspected, provide emotional support and encourage the patient to express her feelings. Prepare her for diagnostic tests, such as ultrasonography, thermography, mammography, nipple discharge cytology, and breast biopsy. If a Candidainfection is suspected, prepare her for skin or blood cultures.
Geriatric pointers
Because of the increased breast cancer risk in this population, breast ulcers should be considered cancerous until proven otherwise. However, ulcers can also result from normal skin changes in the elderly, such as thinning, decreased vascularity, and loss of elasticity as well as from poor skin hygiene. Pressure ulcers may result from restraints and tight brassieres; traumatic ulcers, from falls or abuse.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Corneal ulcers (Professional Guide to Diseases (Eighth Edition))
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