Peau d’orange is an edematous thickening and pitting of the breast skin, giving an orange-peel appearance. It develops slowly and is most often a late sign of breast cancer, but it may also occur with breast or axillary lymph node infections, erysipelas, or Graves’ disease. The characteristic texture results from lymphatic edema around deepened hair follicles.

History and Physical Examination

History

• Onset: Ask when the patient first noticed peau d’orange.

• Associated changes: lumps, pain, nipple discharge, or other breast symptoms.

• Systemic features: malaise, achiness, weight loss.

• Lactation history: Is the patient breastfeeding or recently weaned?

• Surgical history: Previous axillary surgery or procedures that could impair lymphatic drainage.

Physical Examination

• Use good lighting to inspect both breasts.

• Assess the extent of peau d’orange and look for erythema.

• Examine nipples for discharge, deviation, retraction, dimpling, or cracking.

• Palpate the peau d’orange area for warmth, induration, or tenderness.

• Palpate the entire breast for fixed or mobile masses, and check axillary lymph nodes for enlargement.

• Take the patient’s temperature.

Medical Causes

Breast abscess

• Often affects lactating women with milk stasis.

• Presents with:

  • Peau d’orange

  • Breast tenderness and erythema

  • Sudden fever and shaking chills

  • Cracked nipple with purulent discharge

  • Indurated or fluctuant soft mass

Breast cancer

• The most common and serious cause.

• Usually starts in the dependent part of the breast or areola.

• Findings:

  • Firm, immobile mass adherent to overlying skin

  • Skin contour changes, nipple deviation or retraction

  • Thin, watery, bloody, or purulent nipple discharge

  • Burning, itching, warmth, or pain (though pain is an unreliable sign)

Special considerations

• Peau d’orange typically signals advanced breast cancer → provide strong emotional support.

• Allow the patient to discuss fears and concerns.

• Explain expected diagnostic tests: mammography, breast ultrasound, and biopsy.

Patient counseling

• Educate on the importance of early reporting of breast changes.

• Teach proper monthly breast self-examination techniques.

• Discuss diagnostic procedures and follow-up care.

References

1. Sommers MS, Brunner LS. Pocket diseases. Philadelphia (PA): F.A. Davis; 2012.

2. Schuiling KD. Women’s gynecologic health. Burlington (MA): Jones & Bartlett Learning; 2013.