History and Physical Examination

Start by asking the patient when they first noticed the ulcer and if it was preceded by other breast changes such as nodules, edema, nipple discharge, deviation, or retraction. Inquire if the ulcer is improving or worsening and if it causes pain or drainage. Ask if the breast shape has changed and if the patient has had a skin rash. Find out if the patient has attempted home treatment for the ulcer.

Review the patient’s personal and family history for factors increasing the risk of breast cancer, such as previous breast cancer, mastectomy, family history (mother or sister with breast cancer), and age at menarche and menopause. More than 30 years of menstrual activity increases the risk. Also, ask about pregnancy, as nulliparity or childbirth after age 30 increases the risk of breast cancer.

If the patient recently gave birth, ask if she is breastfeeding or has recently weaned her child. Inquire about current oral antibiotic use or diabetes, as these factors can predispose to Candida infections.

Inspect the breast for asymmetry or flattening. Look for signs of a rash, scaling, cracking, or redness around the nipples, areola, and inframammary fold. Pay close attention to skin changes such as warmth, erythema, or peau d’orange. Palpate the breast for masses, noting induration beneath the ulcer, and carefully check for tenderness or nodules around the areola and axillary lymph nodes.

Medical Causes

• Breast Cancer: A breast ulcer that does not heal within a month usually indicates cancer. Ulceration along a mastectomy scar may suggest metastatic cancer, and a nodule beneath the ulcer may indicate a late-stage 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.

• Breast Trauma: Tissue destruction resulting from trauma, with inadequate healing, can lead to breast ulcers. Associated signs may include ecchymosis, lacerations, abrasions, swelling, and hematoma.

• Candida Albicans Infection: Severe Candida infections can cause maceration of the breast tissue, followed by ulceration. This infection typically produces bright-red, well-defined papular patches with scaly borders. It often develops in the breast folds, especially in breastfeeding women with cracked nipples. The pain, described as burning, is felt when the infant sucks, penetrating into the chest wall.

• Paget’s Disease: This condition can cause bright-red nipple excoriation that extends to the areola and ulcerates. Accompanying symptoms may include serous or bloody nipple discharge and intense itching, usually affecting one breast.

Other Causes

Radiation Therapy: Following radiation, the breast may appear “sunburned,” and the skin may ulcerate, becoming red and tender.

Special Considerations If breast cancer is suspected, offer 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 Candida infection is suspected, prepare the patient for skin or blood cultures.

Patient Counseling Instruct the patient on how to apply topical antifungal or antibacterial ointments or creams. Advise her to keep the ulcer dry to minimize chafing and to wear loose-fitting undergarments. Emphasize the importance of regular clinical breast examinations and mammography according to American Cancer Society guidelines. Educate the patient about the cause of the ulcer and the treatment plan once the diagnosis is confirmed.

Geriatric Pointers Due to the increased risk of breast cancer in older adults, breast ulcers should be considered cancerous until proven otherwise. However, ulcers in this age group can also result from normal skin changes, such as thinning, decreased vascularity, and loss of elasticity. Poor skin hygiene can contribute, and pressure ulcers may arise from restraints or tight brassieres. Traumatic ulcers may result from falls or abuse.

References

• Levine, S. M., Lester, M. E., Fontenot, B., & Allen, R. J. (2011). Perforator flap breast reconstruction after unsatisfactory implant reconstruction. Annals of Plastic Surgery, 66(5), 513–517.

• Visser, N. J., Damen, T. H., Timman, R., Hofer, S. O., & Mureau, M. A. (2010). Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction. Plastic and Reconstructive Surgery, 126(1), 26–36.