It is itchy and sometimes pain can be associated with the affected area. The lesion is clearly separated from normal skin in most cases, and sometimes scattered areas of white scale can be present, giving a "strawberries and cream" appearance.Involvement may be extensive including the perianal region, genitocrural, and inguinal folds. Clinical examination should determine the presence of periurethral and perianal lesions. In these cases an involvement of the skin by a noncutaneous internal neoplasm may occur. Pathophysiology
EMPD occurs due to an invasion of the epidermis by Paget cells. The cause of the disease is still under debate with recent research indicating that the disease may be associated with Toker cells. Disease of the vulva
Originates from local organs such as the Bartholin gland, the urethra, or the rectum. Predilection towards postmenopausal women. Metastatic disease
Metastasis of Paget cells from the epidermis to distant regions is a multistep process that involves:

Invasion of local lymph nodes and venous system
Movement out from lymph nodes and venous system
Proliferation at new siteProtein molecules HER2 and mTOR expressed in Paget cells are responsible for providing characteristics of proliferation and survival. Diagnosis
Due to the rarity of EMPD and lack of clinical knowledge, the disease is not very commonly diagnosed. Patients are often misdiagnosed with eczema or dermatitis and a delay of 2 years is expected from the onset of symptoms before a definitive diagnosis has been reached.It is important to include that the lesion is associated with another cancer. A biopsy will establish the diagnosis.
No evidence of natural person-to-person transmission has been found. However, rare cases of transmission from blood transfusions have been reported. The virus which causes Colorado tick fever may stay in the blood for as long as four months after onset of the illness. Diagnosis
A combination of clinical signs, symptoms, and laboratory tests can confirm the likelihood of having CTF. Some tests include complement fixation to Colorado tick virus, immunofluorescence for Colorado tick fever, and some other common laboratory findings suggestive of CTF, including leucopenia, thrombocytopenia, and mildly elevated liver enzyme levels. Detection of viral antibodies on red blood cells is possible. Prevention
To avoid tick bites and infection, experts advise:

Avoid tick-infested areas, especially during the warmer months. Wear light-colored clothing so ticks can be easily seen. Wear a long sleeved shirt, hat, long pants, and tuck pant legs into socks. Walk in the center of trails to avoid overhanging grass and brush. Clothing and body parts should be checked every few hours for ticks when spending time outdoors in tick-infested areas. Ticks are most often found on the thigh, arms, underarms, and legs. Ticks can be very small (no bigger than a pinhead). Look carefully for new "freckles". The use of insect repellents containing DEET on skin or permethrin on clothing can be effective. Follow the directions on the container and wash off repellents when going indoors. Remove attached ticks immediately.Contracting the CTF virus is thought to provide long-lasting immunity against reinfection.