A 75-year-old woman has a scaly, reddened left nipple and areola for 8 months. After a potent topical steroid fails, what is the most appropriate next step in evaluation?

• A. Prescribe a stronger topical steroid and schedule follow-up
• B. Order a mammogram and refer to a breast surgeon
• C. Reassure patient and monitor without imaging
• D. Obtain breast MRI as first-line test

Answer: (B)

Persistent unilateral changes of the nipple-areola in an older woman are concerning for an underlying breast malignancy, such as Paget disease of the breast. When a lesion on the nipple does not respond to potent topical steroids after several months, it’s essential to move beyond symptomatic treatment and evaluate for cancer. The best next step is to obtain imaging with a mammogram to assess for underlying ductal carcinoma in situ or invasive cancer and to refer to a breast surgeon for further diagnostic workup and management. Mammography is the appropriate first-line imaging in this setting; MRI can be considered later if mammography is inconclusive or if high-risk features exist, but it is not the initial test. Reassurance or merely increasing topical therapy would miss a potential malignancy, and delaying imaging could allow cancer to progress.