Milia are very common, benign, keratin-filled epidermoid cysts that occur in individuals of all ages, from infants to elderly persons.
- Primary milia are typically seen in infants but may also occur in children and adults. Primary milia arise on facial skin bearing vellus hair follicles.
- Secondary milia result from damage to the pilosebaceous unit.
- Milia en plaque and multiple eruptive milia are distinct entities.
- Milia are common in all ages and both sexes. Milia affect approximately 50% of infants.
- Multiple eruptive milia and milia en plaque are rare.
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- Milia are superficial, uniform, pearly-white to yellowish, domed lesions measuring 1-2 mm in diameter.
- Milia most often arise on the face and are particularly prominent on the eyelids and cheeks, but they may occur elsewhere.
- They are usually asymptomatic but may be itchy.
- Primary milia in infants occur on the face, especially the cheeks, nose and around the eyes. They may be more widespread on the scalp, face and upper trunk.
- They may also be found on the mucosa (Epstein's pearls) and palate (Bohn's nodules).
- In older children and adults, they also develop on the face, particularly around the eyes.
- Primary milia in children and adults are most often on the eyelids, cheeks, forehead and genitalia. They may clear in a few weeks or persist for months or longer.
- Juvenile milia may be present at birth or appear later in life. They may be associated with Gardner's syndrome and other genetic disorders.
Milia en plaque
- The small papules arise on a distinct, erythematous plaque in the postauricular area, unilaterally or bilaterally.
- They are usually seen on the eyelids, behind the ears, on cheeks or on the jaw. Submandibular plaques and lesions on the pinna have been reported.
- They especially affect middle-aged women and may be associated with other skin disease, eg pseudoxanthoma elasticum, discoid lupus erythematosus, lichen planus.
Multiple eruptive milia
- These are found anywhere on the body where there has been a predisposing condition.
- Traumatic milia occur at site of injury as skin heals, eg following burns or blistering rashes.
- Milia may rarely follow the use of topical medication, eg 5-fluorouracil cream, corticosteroid creams.
- The clinical appearance is diagnostic in simple milia and no further investigations are required.
- In elderly people with sun-damaged skin, a biopsy is needed to exclude nodular elastosis of the skin (Favre-Racouchot syndrome). If milia en plaque are suspected, a biopsy is prudent to confirm the diagnosis.
- Acne vulgaris.
- Lichen planus follicularis tumidus.
- Follicular mucinosis.
Another differential diagnosis is closed comedones which are more cream than white. They also usually have a small punctum as well as being associated with open (black) comedones.
Primary care management
- Often no treatment is required.
- Some milia may be removed with a needle, as they often shell out easily.
- Topical peeling agents do not work.
They are harmless but unsightly. They tend to resolve within a few weeks in infants but may persist in older children and adults, requiring removal with a needle (no anaesthetic is required).
When to refer
For confirmation of diagnosis or reassurance. It is worth referring patients with suspected milia en plaque.
Further reading & references
- Berk DR, Bayliss SJ; Milia: a review and classification. J Am Acad Dermatol. 2008 Dec;59(6):1050-63. Epub 2008 Sep 25.
- Cooper S; Milia, Medscape, Aug 2011
- Milium, milia, DermNet NZ, Jun 2011
- Garcia Sanchez MS, Gomez Centeno P, Rosen E, et al; Milia en plaque in a bilateral submandibular distribution. Clin Exp Dermatol. 1998 Sep;23(5):227-9.
- Smith MA; Localized milia formation on pinna due to topical steroid application. Clin Exp Dermatol. 1977 Sep;2(3):285-6.
- Batra P, Tsou HC, Warycha M, et al; Multiple eruptive milia. Dermatol Online J. 2009 Aug 15;15(8):20.
- Bryden AM, Ferguson J, Ibbotson SH; Milia complicating photocontact allergy to absorbent sunscreen chemicals. Clin Exp Dermatol. 2003 Nov;28(6):668-9.
- Thami GP, Kaur S, Kanwar AJ; Surgical Pearl: Enucleation of milia with a disposable hypodermic needle. J Am Acad Dermatol. 2002 Oct;47(4):602-3.
|Original Author: Dr Hayley Willacy, Dr Olivia Scott||Current Version: Dr Colin Tidy||Peer Reviewer: Dr Huw Thomas|
|Last Checked: 19/08/2011||Document ID: 4061 Version: 24||© EMIS|
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