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.

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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
Nummular eczema (NE) is a dermatologic condition that may
develop postoperatively on the skin of the reconstructed
breast in breast cancer patients [1]. However, literature docu-
menting this entity is rare. In one retrospective analysis,
Iwahira et al. reviewed 1662 Japanese women who under-
went breast reconstruction and found that nearly 3% devel-
oped NE [1]. Lesion onset varied: 45.8% after tissue expander
(TE) placement, 25.0% after silicone implant replacement, and
29.2% after nipple-areola complex reconstruction. Lesion
location also varied, with 41.7% and 66.7% presenting with
peri-wound and non-peri-wound lesions, respectively. In a
more recent study, Rosen et al. identified 21 patients of
unspecified ethnicity who developed a rash on the skin over-
lying the reconstructed breast, diagnosed as ‘post-reconstruc-
tion dermatitis of the breast’; none of these cases were
biopsied and most resolved with topical antibiotics and top-
ical corticosteroids [2]. Because breast cancer is a prevalent
disease and breast reconstruction is a frequent management
strategy, we present the clinical and histopathologic features
of three cases of NE of the reconstructed breast in non-Asian
women.
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
rash on both breasts, which began 10 months after bilateral
mastectomies and reconstruction with implants. On exam,
she had hyperpigmented patches on the right lateral breast
and an erythematous, hyperpigmented, scaly plaque overly-
ing the surgical scar on the left breast (Figure 1(A)). She was
treated with desonide 0.05% ointment with resolution. Three
months later, the plaque on the left breast recurred in the
same area. At that time, a biopsy showed acute spongiotic
dermatitis (Figure 1(B)). She again improved with desonide
0.05% ointment and emollients.
Case 2: A 48-year-old Caucasian female with a history of
DCIS presented with an asymptomatic rash on the right
CONTACT Alexandra K. Rzepecki arzepeck@med.umich.edu
Einstein College of Medicine, 1521 Jarrett, Bronx, NY 10461, USA
ß 2018 Acta Oncologica Foundation
https://doi.org/10.1080/0284186X.2018.1489145
breast overlying the port for TE filling, which developed 10
months after she had undergone a right mastectomy and
reconstruction with TE placement. She noted breast pain but
no pruritus. On exam, she had an erythematous, scaly,
crusted plaque on the mid-breast over the TE port (Figure 2).
The patient refused biopsy. She was prescribed desonide
0.05% ointment. Her TE was replaced with a silicone implant,
but the dermatitis persisted. She did not return for follow-up
but reports the dermatitis eventually cleared without
treatment.
Case 3: A 45-year-old Hispanic female with a history of
invasive ductal carcinoma presented with a pruritic rash on
her right lateral breast, which began five months after neo-
adjuvant chemotherapy, bilateral skin-sparing mastectomies
and reconstruction with TE placement. The rash did not
improve with an emollient or a one-week course of sulfa-
methoxazole/trimethoprim prescribed by her surgeon. On
exam, she had an erythematous, scaly, crusted plaque on the
right lateral inferior breast (Figure 3(A)) and a scaly papule
on her right shoulder. She was treated with fluocinonide
0.05% ointment with improvement (Figure 3(B)). Three
months later, the patient presented with recurrence of the
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)).
Discussion
Breast cancer is the most common cancer diagnosis and the
leading cause of cancer death in women [3,4]. Total mastec-
tomy removes the entire breast tissue and causes significant
morbidity, and breast reconstruction using prosthetic devi-
ces or autologous tissue is often performed to allay psycho-
social distress [5,6]. Currently, it is unclear why breast
surgery may lead to NE. Rosen et al. predicted the etiology
to be a result of skin tension and venous stasis, although
these authors described post-reconstruction dermatitis and
not specifically NE [2]. Iwahira et al. proposed pathophysi-
ology related to transient ischemia of the breast skin, stat-
ing that operative maneuvers during mastectomy can
Montefiore Medical Center Department of Medicine, Division of Dermatology, Albert

Figure 1. Clinical and histopathologic features of nummular eczema (Case 1).
(A) Erythematous, hyperpigmented, scaly plaque overlying the surgical scar on
the left breast. (B) Hematoxylin–Eosin biopsy section showing spongiotic derma-
titis at x10 magnification.
Figure 2. Clinical features of nummular eczema (Case 2). Erythematous, scaly,
crusted plaque on the right mid-breast over the tissue expander port.
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].
Given the limited reports of RBS and NE, especially in the
dermatologic literature, there could be overlap between
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,
clinical features, and epidemiology of NE of the reconstructed
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.

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