Case Study: Erythematous Breast Lesion in a Young Female with Dermatillomania
Case at a Glance
A 19-year-old female with a history of Obsessive-Compulsive Disorder (OCD) and associated dermatillomania presented with a new, asymptomatic, erythematous patch on her breast. The lesion had increased in size over several days, causing significant anxiety about potential malignancy.
Patient's Story
The patient, a 19-year-old female, presented with concerns about a skin lesion on her breast that she first noticed approximately one week prior. Initially, it was a small, well-defined, pinkish-red oval patch. It was neither painful nor pruritic. She noted a subtle change in skin texture at the site. Due to her history of OCD, which manifests as compulsive skin picking (dermatillomania), including on her chest and breasts, she became increasingly anxious about the lesion. Her anxiety was heightened as the patch began to enlarge and become less defined over the last 2-3 days. She also observed new, tiny, pinpoint red marks within the lesion.
Initial Assessment
On presentation, the patient was anxious but otherwise well. Physical examination of the breast, based on her detailed self-report, revealed a single erythematous, macular patch on one breast. The lesion had recently expanded and showed satellite petechiae-like macules. The texture of the affected skin was now similar to the surrounding tissue. A self-examination performed by the patient revealed no palpable masses, breast asymmetry, skin dimpling, or nipple discharge. There was no family history of breast cancer. Her relevant medical history was significant for OCD and dermatillomania.
The Diagnostic Journey
The patient's primary fear was inflammatory breast cancer (IBC), a concern amplified by her anxiety. However, the clinical presentation was not typical for IBC, which usually involves diffuse erythema, edema (peau d'orange), warmth, and tenderness of the breast. Given her age, the localized nature of the lesion, and the absence of other alarming symptoms, malignancy was considered highly unlikely. The differential diagnosis focused on benign dermatological conditions. Possibilities included:
- Contact Dermatitis: An inflammatory reaction to an external substance.
- Nummular Eczema: Characterized by coin-shaped, well-demarcated eczematous plaques.
- Dermatitis Factitia: A self-inflicted lesion resulting from her known compulsive skin-picking behavior.
Final Diagnosis
Suspected Localized Dermatitis, possibly factitial or contact-related. A definitive diagnosis would require in-person evaluation, but the clinical picture strongly suggested a benign inflammatory skin condition rather than a malignancy.
Treatment Plan
A conservative, initial management plan was recommended. The patient was advised to start a two-week trial of a low-potency topical corticosteroid, such as over-the-counter hydrocortisone 1% cream, applied to the affected area twice daily. Concurrently, she was instructed to use a bland, fragrance-free emollient regularly to maintain skin barrier function. Crucially, she was counseled on the importance of avoiding any further manipulation or picking of the area to allow for healing.
Outcome and Follow-up
The patient was advised that if the lesion showed no improvement, worsened, or if new symptoms developed (e.g., pain, warmth, rapid growth) after the two-week trial, she should seek prompt in-person medical evaluation with a general practitioner or dermatologist. Reassurance was provided that her presentation was highly indicative of a common skin condition and not breast cancer. Follow-up would also ideally include a discussion about management strategies for her underlying dermatillomania.