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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 96-98

Pregnancy-associated hyperkeratosis of the nipple/areola


Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Web Publication17-Sep-2019

Correspondence Address:
Dr. Sumit Kar
Department of Dermatology, Venereology and Leprosy, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha - 442 102, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_62_17

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  Abstract 


Hyperkeratosis of the nipple is an uncommon, benign, asymptomatic, acquired condition of unknown pathogenesis. Most cases are bilateral, although unilateral cases had been reported. Breastfeeding is usually not affected. Physiologic changes of the nipple and areola during pregnancy include enlargement, hyperpigmentation, secondary areolae, erectile nipples, prominence of veins, striae, and enlargement of the Montgomery glands or tubercles (hypertrophied sebaceous glands). Women with unilateral primary hyperkeratosis of the nipple and/or areola (HNA) may have bilateral disease during pregnancy (secondary HNA). Pregnancy may also produce thicker, darker lesions. Here, we report a case of pregnancy-associated hyperkeratosis of the nipple in a primigravida. We counseled her about the benign nature of the condition and treated her with topical steroids and moisturizers.

Keywords: Hyperkeratosis of the nipple, pregnancy dermatoses, verrucous lesion


How to cite this article:
Sonkusale P, Kar S, Yadav N, Bonde P. Pregnancy-associated hyperkeratosis of the nipple/areola. J Mahatma Gandhi Inst Med Sci 2019;24:96-8

How to cite this URL:
Sonkusale P, Kar S, Yadav N, Bonde P. Pregnancy-associated hyperkeratosis of the nipple/areola. J Mahatma Gandhi Inst Med Sci [serial online] 2019 [cited 2019 Nov 20];24:96-8. Available from: http://www.jmgims.co.in/text.asp?2019/24/2/96/267016




  Introduction Top


Hyperkeratosis of the nipple can develop as an idiopathic isolated condition or secondary in 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 (HNA). Pregnancy-associated hyperkeratosis of the nipple can be asymptomatic and may persist in the postpartum period. The characteristic clinical and histopathological features of this disorder allow differentiation from various dermatoses. Removal of these lesions by cautery, radiofrequency ablation, or laser is curative.[1]


  Case Report Top


A 22-year-old primigravida, in her third trimester, presented with an asymptomatic, hyperpigmented warty growth over both nipples for 4 months. There was a gradual increase in the size of the lesion for the last 1 month. The patient was concerned about the increase in the size of growth and was worried about the effect on breastfeeding.

Examination revealed focal, yellow-to-tan-colored, hyperpigmented, verrucous plaques with filiform or papillomatous projection with warty surface over both nipples [Figure 1], [Figure 2], [Figure 3]. The patient did not give consent for biopsy. We made a clinical diagnosis of pregnancy-associated hyperkeratosis of the nipple. The patient was counseled about the benign nature of the condition. She was prescribed topical mid-potent steroid (mometasone furoate ointment 0.1%) and moisturizers.
Figure 1: Focal, yellow-to-tan-colored, hyperpigmented, verrucous plaques with filiform or papillomatous projection with warty surface over both nipples

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Figure 2: Focal, yellow-to-tan-colored, hyperpigmented, verrucous plaques with filiform or papillomatous projection with warty surface over the left nipple

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Figure 3: Focal, yellow-to-tan-colored, hyperpigmented, verrucous plaques with filiform or papillomatous projection with warty surface over the right nipple

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  Discussion Top


Physiologic changes of the nipple and areola during pregnancy include enlargement, hyperpigmentation, secondary areolae, erectile nipples, prominence of veins, striae, and enlargement of the Montgomery glands or tubercles (hypertrophied sebaceous gland).[2],[3] During gestation, benign tumors (seborrheic keratosis), skin tags, warts, atopic dermatitis,[4] and conditions associated with HNA (acanthosis nigricans, ichthyosis, and Darier disease) can develop over the nipple.[5],[6] HNA is typically diagnosed in females between puberty and the third decade of life. The lesions of HNA are confluent and verrucous, and their distribution is usually bilateral.[7] Although HNA can worsen and become bilateral in pregnancy,[8],[9] its onset during or immediately after pregnancy has been only exceptionally reported.[6],[7],[8],[9],[10] It has been postulated that endocrine factors may be involved in the etiopathogenesis of HNA because the lesions worsen in pregnancy and have been associated with estrogen therapy.[11],[12],[13]

The onset of HNA is usually in the second or third decade of life. HNA starts only exceptionally in pregnancy, and it exclusively involves the nipple. HNA shows verrucous lesions that are hyperpigmented, confluent, and diffuse, reminiscent of a verrucous epidermal nevus. In our case, lesions were yellow to mildly tan, focal hyperkeratotic, or warty. Regarding the etiology of this disorder, it may represent a physiologic change of pregnancy. This is supported by onset during pregnancy or in the immediate postpartum period and worsening with subsequent pregnancies, which suggest an effect of high estrogen levels during pregnancy.

Treatment in our case included emollients and topical steroids which provided only mild-to-moderate response.

Treatment modalities in HNA include 6% salicylic acid gel and topical calcipotriol. The use of potent keratolytics, such as urea, under occlusion may be effective in this entity. A short course of topical tretinoin has been effective, but significant irritation and recurrence is an adverse effect.[1] A sustained remission of HNA has been maintained with low-dose acitretin combined with calcipotriol. Surgical modalities, such as cryotherapy,[7] shave excision, surgical removal, carbon dioxide laser, and radiofrequency ablation, have been used in unresponsive cases of HNA. Symptomatic, recalcitrant lesions showed a complete response to curettage.[1] In conclusion, our case represents a distinct clinicopathologic presentation of pregnancy-associated nipple hyperkeratosis. This disorder can be differentiated from HNA based on later onset in life, presentation during or immediately after pregnancy, more focal involvement of the nipple, and characteristic histopathological features. In the author's experience, this entity is reasonably common, whereas the onset of nevoid HNA in pregnancy has been only exceptionally reported. Because the lesions can be persistent and symptomatic, physicians should be familiar with pregnancy-associated hyperkeratosis of the nipple and able to counsel the patient appropriately on prognosis and treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Higgins HW, Jenkins J, Horn TD, Kroumpouzos G. Pregnancy-associated hyperkeratosis of the nipple: A report of 25 cases. JAMA Dermatol 2013;149:722-6.  Back to cited text no. 1
    
2.
Wong RC, Ellis CN. Physiologic skin changes in pregnancy. J Am Acad Dermatol 1984;10:929-40.  Back to cited text no. 2
    
3.
Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol 2001;45:1-9.  Back to cited text no. 3
    
4.
Koutroulis I, Papoutsis J, Kroumpouzos G. Atopic dermatitis in pregnancy: Current status and challenges. Obstet Gynecol Surv 2011;66:654-63.  Back to cited text no. 4
    
5.
Alpsoy E, Yilmaz E, Aykol A. Hyperkeratosis of the nipple: Report of two cases. J Dermatol 1997;24:43-5.  Back to cited text no. 5
    
6.
Mehregan AH, Rahbari H. Hyperkeratosis of nipple and areola. Arch Dermatol 1977;113:1691-2.  Back to cited text no. 6
    
7.
Pérez-Izquierdo JM, Vilata JJ, Sánchez JL, Gargallo E, Millan F, Aliaga A, et al. Retinoic acid treatment of nipple hyperkeratosis. Arch Dermatol 1990;126:687-8.  Back to cited text no. 7
    
8.
Rodallec J, Morel P, Guilaine J, Civatte J. Recurring unilateral hyperkeratosis of the areola of the nipples in a pregnant woman. Ann Dermatol Venereol 1978;105:527-8.  Back to cited text no. 8
    
9.
Fenniche S, Badri T. Images in clinical medicine. Nevoid hyperkeratosis of the nipple and areola. N Engl J Med 2010;362:1618.  Back to cited text no. 9
    
10.
Mold DE, Jegasothy BV. Estrogen-induced hyperkeratosis of the nipple. Cutis 1980;26:95-6.  Back to cited text no. 10
    
11.
Vestey JP, Bunney MH. Unilateral hyperkeratosis of the nipple: The response to cryotherapy. Arch Dermatol 1986;122:1360-1.  Back to cited text no. 11
    
12.
Kubota Y, Koga T, Nakayama J, Kiryu H. Naevoid hyperkeratosis of the nipple and areola in a man. Br J Dermatol 2000;142:382-4.  Back to cited text no. 12
    
13.
Levy-Frankel A. Les hyperkeratoses de l'areolaet du mamelon. Paris Med (Paris) 1938;28:63-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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