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Breast clinic consultation: the surgeon explains breast anatomy and Paget's disease of the nipple to a patient — Dr Jérémie Zeitoun, breast surgeon, Paris 8e
Breast cancer · Understand

Paget's disease of the nipple: recognise it, treat it

A redness, a scab or scaling of the nipple that looks like eczema but will not heal: this is how Paget's disease of the nipple can present — a rare form of breast cancer. Its hallmark: this visible skin change is most often the sign of a cancer sitting beneath the nipple. The good news is that it is diagnosed with a simple procedure and treated well when caught in time. Here, from the surgeon's side, is what you need to know.

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Most nipple changes are benign; the aim of a consultation is simply not to miss a diagnosis that is treated well when made early.

It looks like nipple eczema: a redness, some scaling, small crusts, sometimes itching. You apply a cream, it improves a little, then it comes back. What sets Paget's disease of the nipple apart from simple irritation is precisely this persistence: a change that will not heal as it should.

This condition is a rare form of breast cancer (about 1 to 4% of cases). Its hallmark comes down to one image: it is usually the “visible part” of a cancer sitting deeper in the breast — most often a ductal carcinoma in situ, sometimes an invasive cancer. The skin lesion is the signal; it is what hides beneath that guides treatment.

This article explains, from the surgeon's point of view: which signs should alert you, how the diagnosis is made, what is looked for beneath the nipple, and which surgery to offer — conserving or mastectomy. It draws on the SÉNORIF 2025-2026 guideline, the INCa and ESMO, and complements the breast cancer pillar page.

IN BRIEF

What is Paget's disease of the nipple?

Paget's disease of the nipple is a rare form of breast cancer (1 to 4% of cases) in which cancer cells invade the skin of the nipple and areola. It looks like eczema that will not heal, on one side only, despite creams. In close to 9 out of 10 cases a breast cancer is present underneath. The diagnosis rests on a biopsy of the nipple skin.

Nipple eczema or Paget's disease: how to tell them apart

Feature Nipple eczema Paget's disease
Side affected Often both breasts One breast only
Starting point Usually the areola, may reach the nipple The nipple, then the areola — never the reverse
Course Fluctuating, flares and remissions Slowly progressive, over months
Response to steroid creams Clear improvement Failure, or brief improvement then relapse
Distortion of the nipple No Possible: retraction, flattening
What to do Dermatology opinion Biopsy of the nipple skin + mammogram

No single feature settles it. It is the combination — and above all persistence on one side — that makes a biopsy necessary. See also: breast cancer, breast lump, nipple discharge.

A CONDITION BOTH OF THE SKIN AND OF THE BREAST

Understanding Paget's disease

The name comes from the English surgeon Sir James Paget, who described it in the 19th century. Behind a change in the skin of the nipple lies, almost always, a disease of the breast.

Paget's disease of the nipple: a woman whose nipple “eczema” persists despite creams, a sign that should prompt a consultation — Dr Jérémie Zeitoun Paris
The principle

The “visible part” of a breast cancer

In Paget's disease, distinctive cancer cells — Paget cells — migrate into the skin of the nipple and areola (the nipple-areola complex). This is what gives the “eczema” appearance.

But these cells almost always come from a cancer sitting inside the breast, beneath the nipple. Understanding Paget's disease therefore means looking at two levels: the skin you can see, and the lesion looked for beneath it.

01

Rare

It accounts for about 1 to 4% of breast cancers. It mainly affects women after 50, but can, more rarely, occur in men.

02

Rarely isolated

In around 9 out of 10 cases, an underlying cancer is found: most often a ductal carcinoma in situ, sometimes an invasive cancer.

03

One-sided

It affects a single breast and starts at the nipple before spreading to the areola — unlike an ordinary eczema, often on both sides and fluctuating.

The key point: Paget's disease of the nipple (the breast) must not be confused with extramammary Paget disease (vulva, groin, armpit) or Paget's disease of bone, which are entirely different conditions sharing the same name. This article concerns the breast only.

WHAT SHOULD DRAW ATTENTION

The signs that should alert you

The manifestations resemble those of an ordinary skin condition. What matters is not any single sign, but their persistence on one side despite topical treatment.

Redness, crusts, scaling

The nipple becomes red, scaly or crusty, the skin peels or thickens. It may look weepy. These signs start at the nipple and then spread to the areola — never the other way round.

One-sidedStarts at the nipple

Itching, burning, tingling

Itching, a burning or tingling sensation are common. They may precede the visible skin changes and suggest, wrongly, a simple irritation.

Often earlyMisleading

Weeping or bleeding

A serous discharge or slight bleeding from the nipple may occur. A nipple discharge, especially one-sided and spontaneous, always deserves an opinion.

One sideTo be assessed

Retraction, flattening

The nipple may flatten or retract. Sometimes a lump is felt near the nipple — a sign pointing to an underlying lesion to look for.

DistortionSometimes a lump

The simple rule to remember: an ordinary nipple eczema clears with creams within two to three weeks. A nipple change that persists, recurs or worsens despite proper topical treatment should be checked — without panic, but without letting it drift. An examination and, if needed, a biopsy settle the question quickly.

MAKING THE DIAGNOSIS WITH CERTAINTY

The diagnosis: the nipple biopsy

Faced with a nipple lesion that persists, one simple procedure gives certainty: take a small fragment of the nipple skin and analyse it under the microscope.

Diagnosing Paget's disease of the nipple: punch skin biopsy instruments, a procedure performed under local anaesthetic to look for Paget cells — Dr Jérémie Zeitoun Paris

The skin biopsy: the reference test

The diagnosis rests on a biopsy of the nipple skin (a skin biopsy, often taken with a “punch”, a small circular tool), under local anaesthetic. Microscopic analysis (pathology) shows the Paget cells and confirms the diagnosis. It is a quick, well-tolerated procedure, which may be completed by a breast biopsy if imaging shows a deeper abnormality.

01

The mammogram

A mammogram looks for microcalcifications or a mass. It is essential, but can be normal: a normal mammogram does not rule out the disease. This is especially true with dense breasts, where the images are harder to read. If a finding is classified BI-RADS 4 or 5, what happens next is set out in our article on BI-RADS 4 and 5 results.

02

The ultrasound

The breast ultrasound complements the mammogram, particularly to explore the area behind the nipple and the armpit, and to guide a biopsy.

03

The breast MRI

The breast MRI is very useful when the mammogram is normal: it detects and measures a lesion not otherwise visible, and defines its extent before surgery.

Good to know: the diagnosis of Paget's disease is sometimes made late, because the lesion is taken for eczema for months. That is why the message is simple: a nipple lesion that will not heal should be biopsied. The result immediately guides what comes next — usually within a few days to two weeks, as explained in our article on how long breast biopsy results take.

WHO TO SEE, AND WHEN

No biopsy yet?

This is the most common situation, and the order of steps matters. The nipple biopsy comes before the surgical consultation: it is what tells you whether this is Paget's disease or an ordinary skin condition, and therefore whether surgery is called for at all.

  • Your GP, your gynaecologist or a dermatologist examines the lesion and requests the nipple skin biopsy. A dermatologist may perform it directly; a breast radiologist takes over when a deeper lesion is also being targeted.
  • Alongside this, a mammogram and a breast ultrasound are requested, with an MRI added where needed.
  • The result usually arrives within a few days to two weeks.

It is with that result in hand that the surgical consultation becomes truly useful. Dr Zeitoun reviews the pathology report and the imaging, presents the file at the MDT, and sets the strategy: breast-conserving surgery or mastectomy, with or without a sentinel node biopsy, and the reconstruction options.

If the biopsy could not be arranged, or if doubt persists despite a first sample, Dr Zeitoun can perform it himself in clinic. And if a diagnosis has already been made elsewhere, a second opinion before surgery is entirely legitimate.

You have your biopsy result: let's talk about the surgery.

Dr Zeitoun reviews your biopsy report and imaging, sets the surgical strategy and operates — at the Clinique Hartmann in Neuilly.

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THE REAL QUESTION: WHAT DOES THE NIPPLE HIDE?

What is looked for beneath the nipple

The skin lesion signals the disease; it is the deeper lesion that determines its seriousness and treatment. The whole work-up aims to find and characterise it.

Imaging work-up for Paget's disease of the nipple: reading mammograms to find the underlying breast cancer, completed by ultrasound and MRI — Dr Jérémie Zeitoun Paris

A ductal carcinoma in situ

Most often, a ductal carcinoma in situ (DCIS) is found: a “contained” cancer, still inside the ducts, non-invasive. It is the earliest form, with a good outlook when treated. It is the same DCIS that we set out to rule out when a biopsy shows an intraductal papilloma.

“Contained” cancerNon-invasive

An invasive cancer

In a proportion of cases, the underlying lesion is an invasive cancer. The risk is higher when a lump is palpable: one more reason to consult early, before a lump appears.

Crosses the wallRequires node assessment

One area or several?

The work-up establishes whether the disease is localised (a single area, near the nipple) or multifocal/extensive. This distinction is decisive: it points towards breast-conserving surgery or a mastectomy.

Localisedor extensive

The tumour profile

On the samples, the grade of the lesion is specified. Hormone receptors and HER2 are tested only if a cancer is actually found beneath the nipple — and it is then the underlying cancer, not Paget's disease itself, that is characterised. This profile therefore does not apply to every patient: it serves to decide any additional treatment after surgery, at the MDT.

GradeReceptors if a cancer is found

Bear in mind: when there is no palpable lump, the underlying lesion is most often an in-situ cancer, with a very good outlook. The presence of a lump raises more concern about an invasive component — hence the importance of imaging and biopsy to map everything before operating.

THE KEY STEP ON THE SURGEON'S SIDE

The surgery: keep or remove

Surgery is the main treatment. One point is common to every option: the nipple and areola (where the Paget cells sit) must always be removed. This choice between conserving and removing follows the same rules as for other breast cancers — set out in lumpectomy or mastectomy: how the choice is made. The rest depends on what has been found beneath.

Surgery for Paget's disease of the nipple in theatre: excision of the nipple-areola complex in breast-conserving surgery or mastectomy, with sentinel node — Dr Jérémie Zeitoun Paris

Breast-conserving surgery

For localised disease with achievable clear margins, the nipple-areola complex and the affected area are removed (breast-conserving surgery), followed by radiotherapy to the breast. A validated alternative to mastectomy in selected cases.

Keep the breast+ radiotherapy

The mastectomy

If the disease is extensive, multifocal or if clear margins cannot be achieved, mastectomy remains the safest solution. A reconstruction — immediate or delayed — is possible within the same pathway.

Remove the breastReconstruction possible

The sentinel node

For an invasive cancer, or when a mastectomy is performed, the armpit is assessed with the sentinel node — a targeted procedure that often avoids full clearance and its risk of lymphoedema. An isolated in-situ cancer does not always require this step.

Targeted procedureAvoid needless clearance

Reconstructing the nipple

The removed nipple and areola can be reconstructed at a second stage (a small plasty, reconstruction, areola tattoo). Oncoplastic surgery helps preserve a fine breast shape after conservation.

Second stageNatural result

Always a shared decision: the choice between conservation and mastectomy is made at a multidisciplinary team meeting (MDT), according to the extent of the disease, the expected quality of the margins and your wishes. The recovery is generally straightforward.

WHAT THE ANALYSIS SPECIFIES

After surgery: treatments and follow-up

It is the full analysis of the operative specimen that dictates what follows. The additional treatment is not aimed at the “skin” of Paget, but at the cancer found beneath.

After surgery for Paget's disease of the nipple: radiotherapy suite, adjuvant treatment following breast-conserving surgery decided at the MDT — Dr Jérémie Zeitoun Paris
01

Radiotherapy

After breast-conserving surgery, radiotherapy to the breast is usual: it completes the surgery and reduces the risk of local recurrence.

02

Medical treatments

Depending on the underlying cancer: hormone therapy if the tumour is hormone-sensitive, targeted therapies or chemotherapy for an invasive cancer.

03

Follow-up

Regular follow-up (clinical and imaging) is set up. Testing for a genetic predisposition (hereditary breast-ovarian risk) is offered according to family history.

On prognosis: it depends above all on the lesion found beneath the nipple — an in-situ cancer, with no palpable lump, has a very good outlook; an invasive component, or node involvement, is managed differently. The outlook is therefore individual: it is discussed with your team, and no figure can be given from reading an article alone.

DR ZEITOUN'S ROLE

Your pathway with Dr Zeitoun

From the first examination of the nipple to surgery and follow-up, Dr Zeitoun coordinates each step with the multidisciplinary team.

Care pathway for Paget's disease of the nipple: the breast surgeon coordinates diagnosis, surgery and follow-up at the Paris practice — Dr Jérémie Zeitoun

Review & confirm

Most often you arrive with a biopsy result already available. Dr Zeitoun reviews the pathology report and the images, examines the nipple, and completes the work-up if needed. If the biopsy has not yet been done, he can perform it. Prepare your visit with the consultation checklist, and see how to choose a breast cancer surgeon in Paris.

Map & plan

He establishes what lies beneath the nipple, presents your file at the MDT, and offers you the most suitable strategy: conservation where possible, mastectomy where preferable.

Operate with precision

He performs the excision of the nipple-areola complex and the necessary node procedure, thinking from the outset about the aesthetic result and the options for reconstruction.

Paris 8e & Clinique Hartmann

Consultations at the practice in the 8th arrondissement of Paris (241 rue du Faubourg Saint-Honoré), operations at the Clinique Hartmann in Neuilly-sur-Seine. Sector 2 (non-OPTAM): a quote is provided before any procedure.

FREQUENTLY ASKED QUESTIONS

Frequently asked questions

What is Paget's disease of the nipple?

It is a rare form of breast cancer (about 1 to 4% of cases) that shows up as a change in the skin of the nipple and areola. Distinctive cancer cells — Paget cells — are present in the skin of the nipple. In the vast majority of cases, this skin change is the visible sign of a cancer sitting deeper in the breast. It should not be mistaken for a simple eczema. Diagnosis and management are decided at a multidisciplinary team meeting (MDT).

Nipple “eczema” — does it always mean cancer?

No — most nipple changes are benign (eczema, irritation, thrush). But there is a simple rule of thumb: an ordinary eczema clears with creams within two to three weeks. A nipple change that persists, comes back or worsens despite proper topical treatment should be checked, because it may reveal Paget's disease. The point is not to panic, but not to let it drift: a lesion that will not heal deserves an opinion.

Is Paget's disease always linked to a breast cancer?

Almost always. In around 9 out of 10 cases, an underlying cancer is found in the breast: most often a ductal carcinoma in situ (a “contained”, non-invasive cancer), sometimes an invasive cancer. This is exactly why the work-up systematically looks for what lies beneath the nipple: it is that deeper lesion that determines treatment.

How is the diagnosis made?

The key test is a biopsy of the nipple skin (a skin biopsy, often a “punch” biopsy), done under local anaesthetic: it shows the Paget cells. It is completed by imaging — mammogram, ultrasound and often breast MRI — to look for and locate any underlying cancer. Microscopic analysis (pathology) confirms the diagnosis.

Can the mammogram be normal?

Yes. In some patients the mammogram shows no abnormality and there is no palpable lump. A normal mammogram therefore does not rule out the disease: it is the nipple biopsy that makes the diagnosis. Breast MRI is particularly useful in these situations, to detect and measure a lesion not visible on the other tests.

Does the whole breast always have to be removed (mastectomy)?

No, not always. Historically, mastectomy was the rule. Today, for localised disease and when clear margins can be achieved, breast-conserving surgery is possible: the nipple-areola complex and the affected area are removed, followed by radiotherapy to the breast. The choice depends on the extent of the underlying disease and is decided with you, at the MDT.

Can the breast be preserved?

In limited forms, yes — provided the nipple and areola (where the Paget cells sit) are removed completely with clear margins, followed by radiotherapy. Breast-conserving surgery can be combined with oncoplastic techniques, and the nipple can be reconstructed later. If the disease is extensive or multifocal, mastectomy remains preferable.

Are lymph nodes removed?

It depends on what is found beneath the nipple. If there is only a carcinoma in situ, node assessment is not always needed. In the case of an invasive cancer, or when a mastectomy is performed, the armpit is assessed using the sentinel node technique — a targeted procedure that often avoids full clearance and its risk of lymphoedema.

What treatments follow surgery?

They depend entirely on the lesion found beneath the nipple, specified by the analysis of the operative specimen. After breast-conserving surgery, radiotherapy is usual. Depending on the underlying cancer, hormone therapy (if the tumour is sensitive to it), targeted therapies or chemotherapy may be offered. All these decisions are made at the MDT.

Does Paget's disease affect men?

It mainly affects women after 50, but it can, more rarely, occur in men, like male breast cancer. In men as in women, a nipple lesion that persists or bleeds should never be ignored: it warrants a consultation and, if needed, a biopsy.

My biopsy shows Paget's disease: what happens now?

With the diagnosis made, the next step is a breast surgery consultation with your results. Bring the pathology report and all of your imaging (mammogram, ultrasound, MRI if one was performed). The surgeon reviews the file, completes the work-up if needed, presents your case at the multidisciplinary team meeting (MDT), and then proposes a strategy: breast-conserving surgery with excision of the nipple-areola complex, or a mastectomy, with or without a sentinel node biopsy. Reconstruction options are discussed from that first consultation.

Can I ask for a second opinion before having surgery?

Yes, and it is common. A second opinion is your right, it offends no one, and it does not cost you time: Paget's disease progresses slowly, and a few days of reflection do not change the outlook. It is particularly useful when a mastectomy is proposed while you are wondering about keeping the breast, or when you want to discuss reconstruction options. Bring the biopsy report, the images on CD or via a download link, and the MDT record if one already exists.

Read also

To go further into the diagnosis, surgery and treatments of breast cancer.

Overview

Breast cancer

The reference page: diagnosis, surgery and treatments of breast cancer, step by step.

 Understand

Ductal carcinoma in situ

The “contained” cancer most often found beneath Paget's disease: what it changes.

 A symptom

Nipple discharge

When a discharge should be assessed, and what is looked for.

 The diagnosis

The breast biopsy

How a biopsy is done, and what it contributes to the diagnosis.

 Surgery

The mastectomy

When it is needed, how it is performed and the reconstruction options.

 Surgery

The sentinel node

Checking the armpit without needless clearance, for an invasive cancer.

A surgical opinion after a diagnosis of Paget's disease

Your nipple biopsy has shown Paget's disease, or you would like a second opinion before surgery: Dr Jérémie Zeitoun reviews your file, presents your case at the MDT and agrees the surgical strategy with you. Practice in the 8th arrondissement of Paris, operations at the Clinique Hartmann in Neuilly-sur-Seine. Bring your imaging and, where relevant, biopsy reports.

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This article is for information and does not replace a medical consultation; the diagnosis and treatment strategy are established with the multidisciplinary team.

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