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A 34-year-old woman with reddish papules covered silvery scales on right breast and areola area

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Case 6 Presentation


case_6A 34-year-od woman presented with reddish papules covered by silvery-white scales, on her right areola and breast area of a 1-year duration. She had undergone ultrasound mammary scanning one month earlier, no abnormality had been noted. She was married 4 years and reported no itch and no rashes in the groin, perineum and axilla area; no discharge from the nipple during the onset period.

On examination, there was no nipple erosion and discharge, no palpable breast mass, no palpable enlarged axilla lymph node, three papules of diameter 1cm–1.5cm with silvery scales on the areola area, and one salmon-pink plaque with a white scaly surface (Fig.1-A) were seen. Under the scale, the skin had a a glossy homogeneous erythema, and bleeding points appear when the scale is removed. The patient’s temperature, pulse, respiratory rate and blood pressure are in thejrnormal range.

Psoriasis tends to be a symmetric eruption, and symmetry is a helpful feature in establishing a diagnosis; however, unilateral involvement can occur. The psoriatic phenotype may present a changing spectrum of disease expression even within the same patient. The patient received diagnose of psoriasis vulgaris in the initial stage, topical corticosteroids may have few side effects with normal use but continued use may also lead to tachyphylaxis1 and ineffective, instead the gold standard of psoriasis care is to palliate the disease safely and effectively in the long term2, thus the herbal medicine Tangs Psoria3 1440mg three times daily was given as the first-line therapy in place of topical steroids and calcipotriene,3 the patient responded to therapy with marked clinical improvement of the psoriatic lesions (Fig.1-B,C,D). At the end of month 4, complete psoriasis clearance was achieved. No other therapy apart from TANGS was given, because of the continuing response and improvement.

 

 

 

Differential Diagnosis

Other skin disorders, such as Mammary Paget disease (MPD), may look similar to areola psoriasis, but there are differences. Mammary Paget disease (MPD) represents approximately 1 percent to 3 percent of breast neoplasms. The peak incidence is between 50 and 60 years of age. MPD in males is extremely rare; almost all reported cases occurred in women. MPD is almost always associated with underlying in situ or invasive intraductal adenocarcinoma of the breast (up to 98 percent of cases in some studies).4,5 Malignant cells directly extend from the underlying tumor into the epidermis via the lactiferous ducts. Rare cases are reported to have originated primarily in the epidermis of the nipple. MPD frequently presents as a unilateral, erythematous, scaly plaque or patch involving the nipple and occasionally the areola. Ulceration and weeping with an eczematous appearance is frequently present. Nipple erosion and discharge may occur. Retraction of the nipple can be seen. Pain, burning, and pruritus are frequently reported by patients.

Failure to identify and adequately treat cases of MPD can lead to metastatic disease with a poor prognosis. Overall survival in patients with MPD is affected by lymph node status and the presence of an underlying breast mass. Patients with negative lymph nodes have been shown to have a 10-year survival rate of 75 percent to 95 percent, whereas those with positive lymph nodes have a survival rate of 20 percent to 45 percent.4 Patients with a palpable breast mass have a 5-year survival probability of 35 percent to 51 percent, as compared to 75 percent to 82 percent in patients without a palpable mass.5

1. Hengge UR et al: Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006; 54(1):1-15
2. Baker J. Psoriasis. Eur J Dermatol. 2007;17(6):563-4
3. Tony TY: Herose, a herbal medicine for psoriasis. Eur J Dermatol. 2008; 18(3):352-353
4. Fu W, Mittel VK, Young SC: Paget disease of the breast: Analysis of 41 patients. Am J Clin Oncol 24:397, 2001
5. Kollmorgen DR et al: Paget's disease of the breast: A 33-year experience.J Am Coll Surg187:171, 1998