AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Milia are very common, benign, keratin-filled cysts. Primary milia are typically seen in infants but also may occur in children and adults. Secondary milia are observed in a number of blistering disorders and following dermabrasion. Milia en plaque and multiple eruptive milia are distinct entities.

The eMedicine Pediatrics article Milia may be of interest, as may the Medscape Dermatologic Surgery Resource Center.

Pathophysiology

Milia are tiny epidermoid cysts. The cysts may be derived from the pilosebaceous follicle. Primary milia arise on facial skin bearing vellus hair follicles. Secondary milia result from damage to the pilosebaceous unit.

Frequency

United States

Primary milia in newborns are so common that they can be considered normal (occurring in approximately half of all infants). Multiple eruptive milia and milia en plaque are rare entities.

Race

No racial predilection is recognized.

Sex

Sexual prevalence is equal for primary and secondary milia. Eruptive milia and milia en plaque occur more frequently in women.

Age

Milia occur in persons of all ages but are typically found in infants.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

Milia are asymptomatic. In children and adults, they usually arise around the eye. Eruptive milia, as the name suggests, have a rapid onset, often within a few weeks.

Physical

• Skin lesions
• • Milia are superficial, uniform, pearly white to yellowish, domed lesions measuring 1-2 mm in diameter.
  • In milia en plaque, multiple milia arise on an erythematous plaque.¹
• Skin distribution
• • Primary milia, in term infants, occur on the face, especially the nose. They also may be found on the mucosa (Epstein pearls) and palate (Bohn nodules).
  • Primary milia in older children and adults develop on the face, particularly around the eyes.²
  • Milia have been observed to occur in a transverse, linear distribution along the nasal groove in some children.³
  • Secondary milia are found anywhere on the body at the sites affected by the predisposing condition.
  • Eruptive milia occur on the head, neck, and upper body.⁴
  • Milia en plaque manifests as distinct plaques on the head and neck. Plaques have been described in the postauricular area, unilaterally or bilaterally, the cheeks, the submandibular plaques, and on the pinna.^{5, 6}

Causes

• Primary milia are believed to arise in sebaceous glands that are not fully developed, explaining the high prevalence in newborn infants.
• Secondary lesions arise following blistering or trauma due to disruption of the sweat ducts. Milia have been described in association with many disorders, including bullous pemphigoid, inherited and acquired epidermolysis bullosa, bullous lichen planus, porphyria cutanea tarda, and burns. Skin trauma from dermabrasion or radiotherapy can result in milia formation.
• Secondary milia have arisen from a bullous contact dermatitis⁷ and a photocontact allergy to sunscreen.⁸ They have also arisen following treatment of cutaneous leishmaniasis⁹ and after topical nitrogen mustard ointment for plaque stage mycosis fungoides.¹⁰
• Secondary milia have been described following potent topical corticosteroid use.¹¹
• Milia are a feature of a number of very rare genodermatoses (eg, Bazex-Dupré-Christol syndrome).¹² Both primary milia and multiple eruptive milia have been reported as familial disorders with autosomal dominant inheritance.¹³
• The etiology of milia en plaque is unknown.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Milialike idiopathic calcinosis cutis (particularly in persons with Down syndrome)¹⁴

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• No investigations are needed for simple milia. The clinical appearance is diagnostic.
• Investigation of the underlying disease is necessary in persons with secondary milia.

Procedures

• Performing a skin biopsy is necessary only if the diagnosis is in doubt.
• • If milia en plaque is suspected, performing a biopsy is prudent to exclude follicular mucinosis and multiple trichoepitheliomata.
  • In an elderly person with sun-damaged skin, Favre-Racouchet syndrome (nodular elastosis of the skin) needs to be excluded.

Histologic Findings

The histological features are identical to those of epidermoid cysts, but the cysts are much smaller. The milium is usually located in the superficial dermis and has a complete epithelial lining (with a granular cell layer). It contains a variable amount of lamellated keratin. The common primary milia in infants and children are found in the undifferentiated sebaceous hair collar surrounding vellus hair follicles. Milia secondary to blistering are often found in eccrine sweat ducts.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

No topical or systemic medications are effective on primary and secondary milia. Single case reports have demonstrated the success of topical isotretinoin, oral etretinate¹⁵ and minocycline in treating patients with milia en plaque.

Surgical Care

Milia can be safely left alone, but if the patient requests treatment, then incision with a cutting-edge needle and manual expression of the contents are effective.¹⁶ This can be performed without local anesthetic. A paper clip has been successfully used to express the contents of the cyst.¹⁷

Milia en plaque has been treated effectively with electrodesiccation, carbon dioxide laser,¹⁸ dermabrasion,¹⁹ and cryosurgery.²⁰

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Complications

• No systemic complications have been reported.

Prognosis

• Milia seen in infancy tend to spontaneously disappear within the first few weeks of life.
• Milia in older children and adults tend to persist.
• Secondary milia arising from blisters rarely resolve.

Patient Education

• Patients or their parents can be taught how to treat milia with a needle (see Treatment).

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• No significant medicolegal pitfalls are associated with this condition.

ACKNOWLEDGMENTS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Dr. Ravi Ratnavel, to the development and writing of this article.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Acknowledgments
• References

1. Losada-Campa A, De La Torre-Fraga C, Cruces-Prado M. Milia en plaque. Br J Dermatol. May 1996;134(5):970-2. [Medline].
2. Ratnavel RC, Handfield-Jones SE, Norris PG. Milia restricted to the eyelids. Clin Exp Dermatol. Mar 1995;20(2):153-4. [Medline].
3. Akinduro OM, Burge SM. Congenital milia in the nasal groove. Br J Dermatol. Jun 1994;130(6):800. [Medline].
4. Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol. Aug 1997;37(2 Pt 2):353-6. [Medline].
5. García Sánchez MS, Gómez Centeno P, Rosen E, Sánchez-Aguilar D, Fernández-Redondo V, Toribio J. Milia en plaque in a bilateral submandibular distribution. Clin Exp Dermatol. Sep 1998;23(5):227-9. [Medline].
6. Calabrese P, Pellicano R, Lomuto M, Castelvetere M. Milia en plaque. J Eur Acad Dermatol Venereol. Mar 1999;12(2):195-6. [Medline].
7. Inman P. Milia following bullous dermatitis. Br J Dermatol. Feb 1969;81(2):132-3. [Medline].
8. Bryden AM, Ferguson J, Ibbotson SH. Milia complicating photocontact allergy to absorbent sunscreen chemicals. Clin Exp Dermatol. Nov 2003;28(6):668-9. [Medline].
9. Del Giudice P. Milia and cutaneous leishmaniasis. Br J Dermatol. May 2007;156(5):1088. [Medline].
10. Kalayciyan A, Oguz O, Demirkesen C, Serdaroglu S, Kotogyan A. Milia in regressing plaques of mycosis fungoides: provoked by topical nitrogen mustard or not?. Int J Dermatol. Dec 2004;43(12):953-6. [Medline].
11. Iacobelli D, Hashimoto K, Kato I, Ito M, Suzuki Y. Clobetasol-induced milia. J Am Acad Dermatol. Aug 1989;21(2 Pt 1):215-7. [Medline].
12. Barcelos AC, Nico MM. Bazex-Dupré-Christol syndrome in a 1-year-old boy and his mother. Pediatr Dermatol. Jan-Feb 2008;25(1):112-3. [Medline].
13. Heard MG, Horton WH, Hambrick GW Jr. The familial occurrence of multiple eruptive milia. Birth Defects Orig Artic Ser. Jun 1971;7(8):333-7. [Medline].
14. Kotsuji T, Imakado S, Iwasaki N, Fujisawa H, Otsuka F. Milia-like idiopathic calcinosis cutis in a patient with translocation Down syndrome. J Am Acad Dermatol. Jul 2001;45(1):152-3. [Medline].
15. Ishiura N, Komine M, Kadono T, Kikuchi K, Tamaki K. A case of milia en plaque successfully treated with oral etretinate. Br J Dermatol. Dec 2007;157(6):1287-9. [Medline].
16. Thami GP, Kaur S, Kanwar AJ. Surgical Pearl: Enucleation of milia with a disposable hypodermic needle. J Am Acad Dermatol. Oct 2002;47(4):602-3. [Medline].
17. George DE, Wasko CA, Hsu S. Surgical pearl: evacuation of milia with a paper clip. J Am Acad Dermatol. Feb 2006;54(2):326. [Medline].
18. Sandhu K, Gupta S, Handa S. CO2 laser therapy for Milia en plaque. J Dermatolog Treat. Dec 2003;14(4):253-5. [Medline].
19. van Lynden-van Nes AM, der Kinderen DJ. Milia en plaque successfully treated by dermabrasion. Dermatol Surg. Oct 2005;31(10):1359-62, discussion 1362. [Medline].
20. Noto G, Dawber R. Milia en plaque: treatment with open spray cryosurgery. Acta Derm Venereol. Oct-Nov 2001;81(5):370-1. [Medline].

Article Last Updated: May 6, 2008