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Pregnancy-Associated Hyperkeratosis of the Nipple:  A Report of 25 Cases

H. William Higgins, MD; Jennifer Jenkins, MD, MPH; Thomas D. Horn, MD, MBA; George Kroumpouzos, MD, PhD
JAMA Dermatol. 2013;149(6):722-726. doi:10.1001/jamadermatol.2013.128.
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Importance Reported physiologic nipple changes in pregnancy do not include hyperkeratosis and are expected to resolve or improve post partum. Hyperkeratosis of the nipple and/or areola can develop in the context of inflammatory diseases (such as atopic dermatitis), in acanthosis nigricans, as an extension of epidermal nevus, after estrogen treatment, and/or in nevoid hyperkeratosis of the nipple and areola. We performed a clinicopathologic analysis of cases of pregnancy-associated nipple hyperkeratosis.

Observations Twenty-five cases of pregnancy-associated nipple hyperkeratosis identified during a 5-year period (January 1, 2007, through December 31, 2012) are reported. The lesions were bilateral and involved predominantly the top of the nipple. Lesions were symptomatic in 17 patients (68%), causing tenderness or discomfort, pruritus, sensitivity to touch, and/or discomfort with breastfeeding. Nine patients (36%) experienced symptomatic aggravation only during pregnancy or breastfeeding. The lesions persisted post partum in 22 patients (88%). Histopathologic features were conspicuous orthokeratotic hyperkeratosis, with papillomatosis and acanthosis being mild or absent.

Conclusions and Relevance Pregnancy-associated hyperkeratosis of the nipple can be symptomatic and persist post partum. It may represent a physiologic change of pregnancy. The characteristic clinicopathologic features of this disorder allow differentiation from nevoid hyperkeratosis of the nipple and areola. We suggest that this distinctive clinicopathologic entity be called pregnancy-associated hyperkeratosis of the nipple.

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Figure 1. Nipple lesions. A, Bilateral, symmetric distribution. B, Focal involvement of the top of the nipple. C, Involvement of the entire top of the nipple and mild erythema. D, Tan to mildly pigmented, warty papules. E, Desquamation. The focal involvement of the apex of the nipple in B and C is not milk.

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Figure 2. Prominent orthokeratotic hyperkeratosis. A, Biopsy specimen (case shown in Figure 1B) shows prominent orthokeratotic hyperkeratosis and absence of epidermal hyperplasia and papillomatosis (hematoxylin-eosin, original magnification ×10). B, Biopsy specimen (case shown in Figure 1D) shows moderate hyperkeratosis with mild papillomatosis (hematoxylin-eosin, original magnification ×10). Inset shows detached section of overlying stratum corneum demonstrating conspicuous hyperkeratosis. A and B, A mild lymphohistiocytic infiltrate and dilated capillaries in papillary dermis are also shown. C, Histopathologic features of hyperkeratosis of the nipple and areola, such as marked elongation of rete ridges, ramifying epidermal hyperplasia, and conspicuous papillomatosis, are shown for comparison (hematoxylin-eosin, original magnification ×10). These features were not present in our cases.




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