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Endgames Case Review

An unusual localised pigmented skin lesion on the nipple-areola complex

BMJ 2018; 362 doi: (Published 12 July 2018) Cite this as: BMJ 2018;362:k2047
  1. Hao Guo, resident dermatologist1,
  2. Xing-Hua Gao, consultant dermatologist1,
  3. Chang Liu, Phd student, pharmacy,
  4. Jiu-Hong Li, consultant dermatologist1
  1. 1Department of Dermatology, No.1 Hospital of China Medical University, Shenyang, China
  2. 2Department of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
  1. Correspondence to Jiu-Hong Li Pfkl2011{at}

A 62 year old Chinese woman presented with a painless pigmented lesion on the right nipple-areola complex (NAC). The lesion began as a small asymptomatic black spot on the base of nipple five years ago and had gradually increased in size. Physical examination revealed an irregular pigmented macular lesion, about 4×3 cm, on the right NAC (fig 1). The borders of the lesion were darkly pigmented, with scales on the surface. The lesion was painless and moveable from the underlying structures. The woman denied any discharge, pruritus, or history of carcinogen exposure; and her family history was unremarkable.

Fig 1

Skin lesion on the right nipple-areola complex

On palpation, no breast masses or lymphadenopathy were found.


  • 1. What are the differential diagnoses for a pigmented skin lesion on the NAC?

  • 2. What investigations are required?

  • 3. When would a patient with a pigmented skin lesion on the NAC be referred for specialist input?


1. What are the differential diagnoses for a pigmented skin lesion with colour variegation on the NAC?

Differential diagnoses include: eczematous breast conditions, seborrheic keratosis, pigmented Bowen’s disease, pigmented mammary Paget’s disease, and superficial spreading melanoma. In contact dermatitis and eczema, hyperpigmentation appears in the chronic phase.1 In seborrheic keratosis, hyperkeratosis and horn cysts are present. In pigmented mammary Paget’s disease, the lesion occurs on the surrounding skin …

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