Acta Oncologica

ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: https://www.tandfonline.com/loi/ionc20

Nummular eczema of the breast following surgery

and reconstruction in breast cancer patients

Alexandra K. Rzepecki, Jenny Wang, Alexandra Urman, Bijal Amin & Beth
McLellan

To cite this article: Alexandra K. Rzepecki, Jenny Wang, Alexandra Urman, Bijal Amin & Beth
McLellan (2018) Nummular eczema of the breast following surgery and reconstruction in breast
cancer patients, Acta Oncologica, 57:11, 1586-1588, DOI: 10.1080/0284186X.2018.1489145

To link to this article: https://doi.org/10.1080/0284186X.2018.1489145

Published online: 17 Jul 2018.

Submit your article to this journal

Article views: 398

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ionc20
ACTA ONCOLOGICA
2018, VOL. 57, NO. 11, 1586–1592

LETTER TO THE EDITOR

Nummular eczema of the breast following surgery and reconstruction in breast

cancer patients
Alexandra K. Rzepeckia,b , Jenny Wangc, Alexandra Urmand, Bijal Amine,b and Beth McLellanb
a
Department of Dermatology, University of Michigan Medical School, Ann Arbor, MI, USA; bMontefiore Medical Center, Department of
Medicine, Division of Dermatology, Bronx, NY, USA; cDepartment of Dermatology, New York University School of Medicine, New York, NY,
USA; dDepartment of Oncology, Montefiore Medical Center, Bronx, NY, USA; eDepartment of Pathology, Albert Einstein College of Medicine,
Bronx, NY, USA

Introduction breast overlying the port for TE filling, which developed 10

months after she had undergone a right mastectomy and
Nummular eczema (NE) is a dermatologic condition that may
reconstruction with TE placement. She noted breast pain but
develop postoperatively on the skin of the reconstructed
no pruritus. On exam, she had an erythematous, scaly,
breast in breast cancer patients [1]. However, literature docu-
crusted plaque on the mid-breast over the TE port (Figure 2).
menting this entity is rare. In one retrospective analysis,
The patient refused biopsy. She was prescribed desonide
Iwahira et al. reviewed 1662 Japanese women who under-
0.05% ointment. Her TE was replaced with a silicone implant,
went breast reconstruction and found that nearly 3% devel- but the dermatitis persisted. She did not return for follow-up
oped NE [1]. Lesion onset varied: 45.8% after tissue expander but reports the dermatitis eventually cleared without
(TE) placement, 25.0% after silicone implant replacement, and treatment.
29.2% after nipple-areola complex reconstruction. Lesion Case 3: A 45-year-old Hispanic female with a history of
location also varied, with 41.7% and 66.7% presenting with invasive ductal carcinoma presented with a pruritic rash on
peri-wound and non-peri-wound lesions, respectively. In a her right lateral breast, which began five months after neo-
more recent study, Rosen et al. identified 21 patients of adjuvant chemotherapy, bilateral skin-sparing mastectomies
unspecified ethnicity who developed a rash on the skin over- and reconstruction with TE placement. The rash did not
lying the reconstructed breast, diagnosed as ‘post-reconstruc- improve with an emollient or a one-week course of sulfa-
tion dermatitis of the breast’; none of these cases were methoxazole/trimethoprim prescribed by her surgeon. On
biopsied and most resolved with topical antibiotics and top- exam, she had an erythematous, scaly, crusted plaque on the
ical corticosteroids [2]. Because breast cancer is a prevalent right lateral inferior breast (Figure 3(A)) and a scaly papule
disease and breast reconstruction is a frequent management on her right shoulder. She was treated with fluocinonide
strategy, we present the clinical and histopathologic features 0.05% ointment with improvement (Figure 3(B)). Three
of three cases of NE of the reconstructed breast in non-Asian months later, the patient presented with recurrence of the
women. rash in the same area on the right breast. At that time, a
shave biopsy showed spongiotic dermatitis with many eosi-
nophils (Figure 3(C)).
Report of cases
Case 1: A 42-year-old African-American female with a history
of ductal carcinoma in situ (DCIS) presented with a pruritic
Discussion
rash on both breasts, which began 10 months after bilateral Breast cancer is the most common cancer diagnosis and the
mastectomies and reconstruction with implants. On exam, leading cause of cancer death in women [3,4]. Total mastec-
she had hyperpigmented patches on the right lateral breast tomy removes the entire breast tissue and causes significant
and an erythematous, hyperpigmented, scaly plaque overly- morbidity, and breast reconstruction using prosthetic devi-
ing the surgical scar on the left breast (Figure 1(A)). She was ces or autologous tissue is often performed to allay psycho-
treated with desonide 0.05% ointment with resolution. Three social distress [5,6]. Currently, it is unclear why breast
months later, the plaque on the left breast recurred in the surgery may lead to NE. Rosen et al. predicted the etiology
same area. At that time, a biopsy showed acute spongiotic to be a result of skin tension and venous stasis, although
dermatitis (Figure 1(B)). She again improved with desonide these authors described post-reconstruction dermatitis and
0.05% ointment and emollients. not specifically NE [2]. Iwahira et al. proposed pathophysi-
Case 2: A 48-year-old Caucasian female with a history of ology related to transient ischemia of the breast skin, stat-
DCIS presented with an asymptomatic rash on the right ing that operative maneuvers during mastectomy can

CONTACT Alexandra K. Rzepecki arzepeck@med.umich.edu Montefiore Medical Center Department of Medicine, Division of Dermatology, Albert
Einstein College of Medicine, 1521 Jarrett, Bronx, NY 10461, USA
ß 2018 Acta Oncologica Foundation
https://doi.org/10.1080/0284186X.2018.1489145
 ACTA ONCOLOGICA 1587

damage the skin at the incisional margin, causing decreased

blood supply to the breast skin, and further that patients
with thicker subdermal fat layers may have lower incidence
of NE due to better shock absorption [1]. However, our
cases argue against thin body habitus or ethnicity playing a
role in NE development. There is a broad differential diag-
nosis of dermatitis on the breast after breast surgery,
including a reaction to implant materials, human adjuvant
disease, red breast syndrome (RBS), soft tissue infection,
and cutaneous metastases of breast cancer. Iwahira et al.
discuss the possibility of human adjuvant disease, where
foreign materials provoke an immunological response
resulting in skin lesions [7]. However, human adjuvant dis-
ease results in abnormal granulation tissue between foreign
and natural tissue and persistent disease as long as the for-
eign material is present. As Iwahira et al. noted in their
patient population, and as noted in our cases, granulation
tissue was absent, and patients improved even when TE or
implant remained in place [1].
The differential diagnosis also includes RBS, a noninfec-
tious, erythematous rash generally described with acellular
dermal matrix (ADM) use in breast reconstruction [8]. RBS
tends to occur days to weeks following reconstruction,
improves spontaneously or with corticosteroids [8], and
decreases in frequency if ADM is adequately rinsed before
use [9]. Given the time course, RBS is often confused for cel-
lulitis, though clinical features of infection are absent and
erythema is unresponsive to antibiotics [10]. Ganske et al.
demonstrated histological evidence of a hypersensitivity reac-
tion in RBS, with biopsy revealing epidermal spongiosis and
eosinophilic infiltrate, which is similar to our patients [10].
Figure 1. Clinical and histopathologic features of nummular eczema (Case 1). Given the limited reports of RBS and NE, especially in the
(A) Erythematous, hyperpigmented, scaly plaque overlying the surgical scar on
the left breast. (B) Hematoxylin–Eosin biopsy section showing spongiotic derma- dermatologic literature, there could be overlap between
titis at x10 magnification. these two diagnoses. Because prosthesis removal is often rec-
ommended for RBS, increasing awareness and understanding
of these two diagnoses is crucial.
In a patient with breast cancer, new skin lesions should
raise suspicion for cutaneous metastases of breast cancer. All
patients reviewed by Iwahira et al. and our own patients
improved either spontaneously or with steroid ointments,
and biopsies, when performed, were benign [1]. A patient
refractory to steroids should always be biopsied to rule out
cancer.
Poor understanding of NE and RBS as well as potential for
high morbidity in cases of infection may result in patients
with any erythema on the breast post-reconstruction under-
going excessive diagnostic workups, prolonged antibiotic
use, and sometimes surgical removal of prostheses, further
scarring the breasts causing emotional trauma. Thus, we sug-
gest that while infection and metastases must be considered,
a trial of a low-to-mid-potency topical steroid, and skin
biopsy can often precede surgical intervention. Increased rec-
ognition of NE as a possible diagnosis for rash on the recon-
structed breast can prevent excessive diagnostic workup,
aggressive management, and worse quality of life outcomes
in breast cancer patients. Further research in broader study
populations is necessary to elucidate the pathophysiology,
Figure 2. Clinical features of nummular eczema (Case 2). Erythematous, scaly, clinical features, and epidemiology of NE of the reconstructed
crusted plaque on the right mid-breast over the tissue expander port. breast.
1588 LETTERS TO THE EDITOR

Figure 3. Clinical features before and after therapy with fluocinonide ointment, and histopathologic features of nummular eczema (Case 3). (A) Erythematous, scaly,
crusted plaque on the right lateral inferior breast. (B) Therapy results three months after fluocinonide 0.05% ointment treatment. (C) Hematoxylin–Eosin biopsy sec-
tion showing spongiotic dermatitis with eosinophils at x10 magnification.

IRB approval overview of the breast health global initiative global summit 2007.
Cancer 2008;113:2221–2243.
This study was exempted from review by the institutional [4] Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of can-
IRB. cer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893–2917.
[5] McGuire KP, Santillan AA, Kaur P, et al. Are mastectomies on the
rise? A 13-year trend analysis of the selection of mastectomy ver-
sus breast conservation therapy in 5865 patients. Ann Surg
Disclosure statement Oncol. 2009;16:2682–2690.
[6] Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast
No potential conflict of interest was reported by the authors.
reconstructive surgery in physical and emotional outcomes
among breast cancer survivors. J Natl Cancer Inst. 2000;
ORCID 92:1422–1429.
[7] Martinez-Villarreal AA, Asz-Sigall D, Gutierrez-Mendoza D, et al. A
AlexandraK. Rzepecki http://orcid.org/0000-0002-2976-1861 case series and a review of the literature on foreign modelling
agent reaction: an emerging problem. Int Wound J
2017;14:546–554.
[8] Wu PS, Winocour S, Jacobson SR. Red breast syndrome: a review
References of available literature. Aesthetic Plast Surg. 2015;39:227–230.
[9] Lewis P, Jewell J, Mattison G, et al. Reducing postoperative infec-
[1] Iwahira Y, Nagasao T, Shimizu Y, et al. Nummular eczema of breast: tions and red breast syndrome in patients with acellular dermal
a potential dermatologic complication after mastectomy and sub- matrix-based breast reconstruction: the relative roles of product
sequent breast reconstruction. Plast Surg Int. 2015;2015:209458 sterility and lower body mass index. Ann Plast Surg. 2015;74:
[2] Rosen A, Goh C, Lacouture M, et al. Post-reconstruction dermatitis S30–S32.
of the breast. J Plast Reconstr Aesthet Surg. 2017;70:1369–1376. [10] Ganske I, Hoyler M, Fox SE, et al. Delayed hypersensitivity reaction
[3] Anderson BO, Yip CH, Smith RA, et al. Guideline implementation for to acellular dermal matrix in breast reconstruction: the red breast
breast healthcare in low-income and middle-income countries: syndrome? Ann Plast Surg. 2014;73(Suppl 2): S139–S143.