What you need to know first
What skin and nipple changes might be
Causes vary widely with the specific change. The most important to recognise:
Dimpling, puckering, or skin tethering
Skin dimpling that is new — particularly if it appears or worsens when you raise your arms above your head — can be caused by a tumour pulling on the supporting fibrous tissue of the breast (called Cooper’s ligaments). It can also be caused by benign conditions such as scarring from previous surgery or injury, or fat necrosis. Any new dimpling should be assessed.
Peau d’orange (orange-peel skin)
Thickened skin with a pitted, orange-peel texture over part of the breast is a specific sign that warrants urgent assessment. It can be caused by inflammatory breast cancer — an uncommon but aggressive form of breast cancer — or by lymphatic congestion from other causes including radiotherapy, cellulitis, and some benign conditions.
Redness, warmth, or swelling
A red, warm, swollen breast is most commonly caused by mastitis or a breast abscess, particularly in women who are breastfeeding. It can also be caused by cellulitis, eczema, or a reaction to something topical. However, inflammatory breast cancer can look very similar to mastitis and does not improve with antibiotics. A breast infection that does not respond to antibiotics within a week or two always needs specialist review.
Nipple rash, eczema, or crusting — Paget’s disease
A persistent, unilateral (one-sided), scaly, itchy, or crusted change on the nipple and areola that does not respond to standard eczema treatment should be assessed for Paget’s disease of the nipple — a form of breast cancer that starts in the skin of the nipple. Paget’s disease can look almost identical to eczema, which is why the “persistent, one-sided, doesn’t respond to treatment” pattern is so important.
Paget’s disease is not common, and most nipple rashes are benign eczema or dermatitis — but the distinction matters.
New nipple inversion
Some women have had nipples that turn inwards since adolescence or after breastfeeding — this is a normal variant and not concerning. A newly inverted nipple — one that has turned inwards when it previously pointed outwards — can be caused by benign conditions such as duct ectasia or be a sign of an underlying breast cancer. Any new inversion should be assessed.
Change in shape or contour
A visible new difference in shape, fullness, or contour between the two breasts can be caused by hormonal changes, weight change, previous surgery — or, occasionally, by an underlying tumour distorting the breast tissue.
The probability of breast cancer underlying each of these changes varies widely. Overall, most new breast skin changes are benign, but the specific patterns named above — persistent unilateral nipple rash, new dimpling, new inversion, and peau d’orange — carry enough risk to warrant a full specialist assessment.
How skin changes are assessed
Skin and nipple changes are assessed using triple assessment, adapted to the specific change:
- Clinical examination. Careful inspection and palpation of both breasts, the nipples, and the armpits. Photographs may be taken (with your consent) to document the appearance and to allow comparison at follow-up.
- Imaging. Mammogram (in women aged 40 and over) and ultrasound are the usual first tests. MRI is sometimes added — particularly for inflammatory-looking changes, peau d’orange, or suspected Paget’s disease.
- Biopsy, where indicated. For nipple changes with a pattern consistent with Paget’s disease, a skin punch biopsy of the affected nipple skin is often done under local anaesthetic. For underlying lumps or abnormal imaging, a standard core needle biopsy is performed. Not every skin change requires a biopsy.
What happens after the assessment
As with any breast-symptom assessment, you will typically leave with one of four outcomes:
- Reassurance — the change is clearly benign (eczema, dermatitis, old surgical scar, normal variation) and no further action is needed; a simple management plan may be given (for example emollient or hydrocortisone for true eczema).
- A benign diagnosis with a plan — for example duct ectasia with nipple inversion, or an infection needing further treatment.
- Awaiting biopsy results — where a sample has been taken and histology is pending.
- A diagnosis needing onward investigation or treatment — including referral into a multidisciplinary cancer pathway when needed.
A letter to your GP is sent after every appointment with your permission.