Pediatric Dermatology Vol. 32 No.

5 718–722, 2015

Unilateral Nipple Eczema in Children: Report of

Five Cases and Literature Review
David Jenkins, M.B.B.S., Susan M. Cooper, M.D., F.R.C.P., and Tess McPherson, M.A., M.D.,
M.B.B.S., M.R.C.P.
Oxford University Hospitals, Oxford, UK

Abstract: Bilateral nipple eczema on the background of atopy is not an

uncommon problem and is a minor criterion in some diagnostic systems
for atopic dermatitis (AD), but unilateral atopic nipple eczema is under-
recognized and often causes clinical concern. We present the first case
series of children with unilateral atopic nipple eczema and discuss the
clinical aspects of this unusual distribution.

Atopic dermatitis (AD) is generally a symmetrical revealed a poorly defined erythematous eruption with
process, and nipple involvement is no exception. A scale, excoriations, and oedema across the left areola
unilateral eruption of the areola and nipple can cause and nipple. There were no other skin signs.
diagnostic confusion among medical practitioners or
raise concerns about a more serious condition, such as
Patient 2
infection or Paget’s disease. We present a series of five
children, all with a family history of atopy and onset An 18-month-old boy was referred by his pediatrician
of eczema in infancy, who presented to the Oxford with a 1-year history of an episodic pruritic eruption
Dermatology Department with unilateral nipple of the right nipple area. He also had a background of
eczema. mild AD that had not been problematic for some
time. There was no response to a course of floxacillin
and the use of combined clobetasone, oxytetracycline,
CASE REPORTS nystatin cream. Examination revealed a hyperkera-
totic, lichenified right areola (Fig. 1). No other areas
Patient 1
were affected. With the below-listed treatment,
A 15-month-old girl was referred by her general lichenification and postinflammatory hyperpigmenta-
practitioner (GP) with a 10-month history of a tion took some time to normalize, however, symptoms
stubborn left nipple rash on a background of mild responded quickly (Fig 2).
facial and flexural eczema that had been successfully
treated with emollients, oral antibiotics, and weak
Patient 3
topical corticosteroids. The nipple had a subtotal
response to these treatments and the rash recurred A 9-month-old girl was referred by her GP with a 5-
soon after cessation of the creams. Examination month history of a predominantly one-sided nipple

Address correspondence to David Jenkins, M.B.B.S., Unit 4,

63 Narara Road, Adamstown, NSW 2289, Australia, or e-mail:
dwtjenkins@[Link].

DOI: 10.1111/pde.12612

718 © 2015 Wiley Periodicals, Inc.

 Jenkins et al: Unilateral Nipple Eczema 719

Figure 3. Close-up of an eczematous eruption restricted

to the nipple and areola of patient 4.
Figure 1. Initial presentation of patient 2 with an isolated,
unilateral, pruritic, lichenified plaque replacing the normal
architecture of the right nipple and areola. butyrate ointment for flares. His parents had been
avoiding topical corticosteroids to the nipple area
because they were concerned about cutaneous infec-
tion. On examination, his left nipple had erythema,
oedema, and scale with focal erosions (Figs. 3 and 4).
On review 8 weeks after treatment, there was consid-
erable improvement of symptoms, with only a small
amount of residual swelling remaining (Figs. 5 and 6).
He has remained well controlled with the application
of emollients and topical clobetasone butyrate oint-
ment to active eczema as required.

Patient 5
A 2-year-old boy was referred by his GP with a plaque
of weepy, excoriated erythema across his right nipple
and areola (Figs. 7 and 8) on a background of
Figure 2. Patient 2 in early treatment shows significant intermittent mild flexural eczema and a few scattered
improvement of both symptoms and appearance. discoid areas of eczema. His nipple area had a good
Improvement continued with further treatment. response to empiric treatment as described below
(Fig. 9). He had since been stable on emollient use for
eruption associated with two other small areas of rash the following 3 months.
on the trunk. She had failed multiple trials of topical
and oral antibiotics, emollients, topical antifungal
Treatment Regimen
agents, and weak topical corticosteroids. Examina-
tion of the left nipple revealed erythematous, scaly, All patients had a family history of atopy and were
papular lesions, coalescing into a plaque, with exco- otherwise healthy. There were no relevant exposures
riation in some areas. A fungal scraping performed to to contact allergens or physical stressors noted in any
exclude dermatophyte was negative. of the cases nor any asymmetry in their exposure
patterns before being seen in clinic. Unilateral AD
was provisionally diagnosed in each patient. There
Patient 4
was a lichen simplex chronicus crossover picture in
A 13-month-old boy was referred by his GP with a patient 2 and a discoid eczema crossover in patient 5.
3-month history of an itchy swollen nipple. There was A standard skin care regime for eczema was used in
no response to topical fusidic acid cream and a course each case, including emollients and soap avoidance.
of floxacillin. He had mild atopic eczema that was well Topical corticosteroid was administered by applying
controlled with emollients and occasional clobetasone fludroxycortide 4 lg/cm2 impregnated tape to the
720 Pediatric Dermatology Vol. 32 No. 5 September/October 2015

Figure 4. Unlateral nipple eruption in patient 4. Figure 6. Improvement with treatment in patient 4.

Figure 5. Close-up of improvement with treatment in

patient 4.
Figure 7. Unilateral nipple eczema in patient 5.

area until it peeled off (3–5 days), with a new piece of dyspigmentation taking a number of months to
tape applied if necessary for up to 2 weeks or until regress in patients 2 and 4. There were no significant
clinical improvement. Alternatively, clobetasol or recurrences and patients were maintained on regular
mometasone 0.1% ointments was applied to the area emollients, with topical corticosteroids used for active
for 2 weeks. Parents reported good tolerability and eczema in other areas as required for localized flares.
satisfaction with the regime and Infant Dermatitis Follow-up ranged from 6 weeks to 9 months.
Quality of Life Index scores dropped significantly,
reflecting response to this regime in all five patients. DISCUSSION
The acute symptoms of erythema, edema, crusting,
scale, and fissuring responded within the first 1 to Classical cases of AD, especially when chronic, can be
2 weeks in every case, with lichenification and easily recognized, and clinicians infrequently refer to
 Jenkins et al: Unilateral Nipple Eczema 721

unnecessarily with antibiotics, and appropriate ther-

apy was delayed.
A large number of other skin conditions can affect
the nipple area, but in children they are all uncommon
or rare. The differential diagnosis includes other
eczemas. For example, in adults, reports of ill-fitting
brassieres and “joggers,” “cyclists,” and “surfers”
nipples exist in the literature (3–6). These relate to the
irritant effects of abrasive physical forces, moisture,
and temperature on the skin. Breastfeeding mothers
can also have form of irritant nipple eczema.
Although more commonly bilateral, contact
allergy can also present with unilateral nipple eczema.
Reactions to medications (propolis, beeswax, lanolin,
chamomile ointments) and nail varnish have been
Figure 8. Close-up of the eruption on the right nipple of
patient 5. described in this distribution (7). We considered the
possibility of allergic contact dermatitis in each of our
cases, but we did not feel that patch testing was
necessary. This is because all of our patients had a
positive personal and family history of atopy and no
likely allergens were unilaterally applied to the
nipples, apart from topical over-the-counter prepara-
tions and medicaments. Allergy to these topicals was
excluded because all our cases had been using these
treatments elsewhere on the body with no adverse
reactions. There had generally been avoidance of
topical treatments to the nipple area because of
concerns about side effects. Moreover, there was
improvement with emollients and appropriate topical
corticosteroids, and there have been no reports of
rebound after cessation of treatment. Therefore
allergy to vehicles, medications, and corticosteroids
is unlikely.
Figure 9. Improvement in patient 5 with treatment. In summary, although contact allergy can occa-
sionally be indistinguishable from AD, a lack of
formal criteria to confirm the diagnosis, but various relevant exposure on history, the unilaterality of the
scoring systems exist, mostly to facilitate a benchmark lesions, and the absence of reactions in other areas
for study design. Although not listed in more modern argues against this. Patch testing can be performed on
incarnations, the original criteria that Hanifin and toddlers, but the available body surface for testing is
Raika described in 1980 included nipple eczema as a limited and the practicalities remain a challenge.
minor criterion, which other groups have validated Therefore, because of strong diagnostic suspicion of
(1,2). undertreated atopic eczema, patch testing was con-
Nipple involvement in AD is usually bilateral and sidered unnecessary.
associated with other clinical features such as pruri- The differential diagnosis includes other inflamma-
tus, recurrent episodes, involvement of other sites, and tory dermatoses such as seborrheic eczema. Impetigo
a family history of atopy. In this setting, especially or herpes simplex virus can superinfect existing
when the morphology is typically eczematous, even eczema, although they may also erupt on normal
unilateral nipple disease is easily identified, but when skin. Dermatophyte infection and fixed drug erup-
it is the only problem, the diagnosis of AD of the tions are also typically unilateral and can be limited to
nipple may not be so intuitive. The different color and the nipple. Psoriasis is uncommon in this distribution
texture of the areola and nipple skin alters the classic and age group and is also usually symmetrical.
eczematous appearance, which serves to compound The most sinister connotation of unilateral nipple
the confusion. In our series, children were treated rash is neoplastic change, but this is exceedingly rare
722 Pediatric Dermatology Vol. 32 No. 5 September/October 2015

in this population. Atypical features such as underly- description of this unusual distribution of AD. Skin
ing masses, induration, and disproportionate bleeding swabs and a fungal scraping should be collected
should be excluded. Some authors insist on biopsy of where indicated, but patch testing can be reserved for
unilateral erythrosquamous rashes in adults. This is cases that have a poor response to topical treatments,
predicated on descriptions in the literature of Paget’s and invasive investigations such as biopsy are usually
disease mimicking dermatitis by spontaneously remit- not required. In our experience, unilateral nipple
ting and then relapsing (8), but Paget’s is so uncom- eczema is generally due to undertreatment of AD and
mon in children that a trial of empiric therapy in this a trial of aggressive empiric treatment is warranted.
age group is warranted, with the cases that do not
respond going on to biopsy.
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To the best of our knowledge, this is the first