Treating Milia

Independent nurse prescriber Louise Walsh provides insight into the different types of milia and shares methods of treatment and prevention What is milia and how does it form? There are commonly two types of milia; primary and secondary. Primary milia comprises benign, keratin-filled cysts, derived from the pilosebaceous follicle, seen just under the skin’s surface,1 whereas secondary milia is an inflammatory condition characterised by plaques of milia.2,3,4 In children and adults (both men and women), they usually arise around the eye and on the cheeks; there is no evidence to explain exactly why these areas are affected more than others, but it may be because the skin is often thinner in these locations.5 Primary milia is frequently seen in infants, typically referred to as milk spots which often resolves itself. However, milia seen in adults is usually chronic; the evidence for why is unknown. It can be regarded as unsightly for some individuals and is difficult to cover with make-up due to its bumpy effect. The cause of milia in infants is also unclear, however there is some research that suggests milia in adults is caused initially by skin damage and/or the use of products with mineral oil and lanolin ingredients, such as emollients. It potentially arises because the skin is unable to absorb the product and there is a build-up within the follicle over time.6 It is not uncommon to see milia in aesthetic clinics as, nowadays, patients are frequently seeking skin rejuvenation treatments and may be conscious of this condition. Often, patients will have tried to treat their milia like regular breakouts but quickly learn that it isn’t as easily resolved. In this article, I discuss the typical clinical presentations and how to treat and prevent milia.

Clinical presentation and diagnosis

Primary milia On physical assessment, primary milia is firm, sub-dermal, uniform, pearly white to yellowish, with domed lesions usually measuring 1-3mm in diameter. The lesions are asymptomatic, non-itchy and commonly develop on the face, particularly around the eyes. It is common to see a single milia, as well as groups of 3-10 milium.5 No investigations are needed for the diagnosis of primary milia. The clinical appearance is diagnostic enough.6 Secondary milia Secondary milia manifests as distinct plaques such as in Figure 1; this is a rare inflammatory condition characterised by plaques of milia in the periauricular area.2,3,4 These plaques can develop following trauma to the skin, for example, after a burn, in a blistering disorder such as epidermolysis bullosa, following a resurfacing skin treatment and even after tattooing.7,8 Secondary milia has also been described following potent topical corticosteroid use.9 These are all thought to be a result from damage to the pilosebaceous unit. Unlike primary milia (shown in Figure 2) which needs no further investigations, it is essential to investigate the underlying inflammatory condition that is present with secondary milia to address the initial problem to avoid secondary milia reoccurring.10

Multiple eruptive milia Multiple eruptive milia is also a rare condition and is characterised by the sudden development of crops (patches) of milia over the course of weeks to months. If your patient has an acute history of milia it will need to be considered that they may be at risk of multiple eruptive milia.11,12 Eruptive milia can occur on the head, neck, and upper body.13 It is broken down into three categories:14,15

1. Spontaneous without a known cause or association (i.e. idiopathic) 2. A familial pattern with autosomal dominant transmission 3. A component of a genodermatoses. It is noted that only six cases of idiopathic multiple eruptive milia have been reported in the

English literature.14,15

Both primary milia and multiple eruptive milia have been reported as familial disorders with autosomal dominant inheritance.16,17

Management of milia Although milia is harmless and treatment is not necessary, when the milia does not resolve itself (as it often does in babies) there are a few treatment options for adults to consider, which are now commonly being offered within aesthetic clinics. No topical or systemic medications are effective to treat primary and secondary milia, however single case reports have demonstrated the success of topical tretinoin.16

Treatment options Deroofing is the most commonly-utilised technique where a sterile needle pierces the skin, then the milia is taken out with the blade of the needle. The milia can often be scooped out whole, as it is

Figure 1: Secondary milia resulting from a chemical burn, potentially from a skin peel where the eyes weren’t protected adequately. Images courtesy of Primary Care Dermatology Society22

Differential diagnosis To avoid misdiagnosis and incorrect choice of treatment, it is always worth ruling out other skin conditions which may appear similar on assessment, such as: • Acne vulgaris: specifically the closed comedones on the face • Syringoma: skin coloured lesions around the eyes • Xanthelasma: yellow plaques around the eyes • Trichoepithelioma: slow-growing, single or multiple papules or nodules on the face

quite firm in texture. For a successful outcome, it is important to ensure the whole milium is removed. This procedure is fast and has minimal risks if an aseptic technique is followed. It typically leaves the patient with a small graze where the milia was, which should heal quickly. Hyfrecation can be used to shatter and dehydrate the cyst.18 With this treatment option, a fine tip needle is used which delivers either an electric current or radiofrequency. This is usually only available in clinics where there is a dermatologist working within the team. As well as this, cryotherapy is sometimes used to freeze the cyst; Figure 2: A single primary milia. Images this can leave a small courtesy of Primary Care Dermatology Society22 blister, which should resolve over a week or so. Secondary milia has also been treated effectively with electrodesiccation (the drying of tissue through the use of electrical current) or carbon dioxide laser (also known as co2 laser that uses short pulsed light energy).19-21

Risks and complications of treatment When choosing an appropriate treatment method, it is vital to be confident and competent with the procedure and its associated risks and outcomes. Milia is often located near the eyes, which makes it a high-risk region to work on. It is important that you have a steady hand and your patient is reassured and unlikely to jump. Clearly detailing what is to come in your consultation process should help to prevent this. As with most treatments that compromise the skin, infection, bleeding and swelling are all potential risks. Scarring needs to be discussed thoroughly during the consultation process as some patients may prefer to keep the milia, rather than gain a possible scar. The treatment options mentioned will cause discomfort and others may require local anaesthetic, (for the treatment of hyfrecation, for example) which then carries risks of allergic reactions. None of the procedures can guarantee that the milia will be completely removed, although a good result is commonplace. It is also important to manage patients’ expectations as milia can return.

Prevention advice As milia can return, retinols (under guidance) and gentle skin peels are recommended to keep the skin soft and encourage cell renewal, if suitable for the patient’s skin-type and lifestyle.23 It is also good practice to remind patients to avoid skin products which contain mineral oils and lanolin to prevent the chances of reoccurrence.

It is not uncommon to see milia in aesthetic clinics as, nowadays, patients are frequently seeking skin rejuvenation treatments and may be conscious of this condition

Conclusion Primary milia is completely harmless and very common. In our current times, our patients are more-often-than-not striving for immaculate unblemished skin, so the desire for milia to be removed is on the increase and having the skill to do so is a great asset to any practice.

Louise Walsh is an independent nurse prescriber, dermatology nurse, the owner of aesthetics business The Skin Nurse and practises at The Waldegrave Clinic in Teddington, London. Walsh has experience with various types of wound care and skin management approaches, both post operatively and in an urgent care setting, and now carries out minor-op procedures and acne clinics for the NHS.

REFERENCES

1. Kurokawa I, Kakuno A, Tsubura A. Milia may originate from the outermost layers of the hair bulge of the outer root sheath: A case report. Oncol Lett. 2016 Dec. 12 (6):5190-5192. 2. Garcia Sanchez MS, Gomez Centeno P, Rosen E, Sanchez-Aguilar D, Fernandez-Redondo V, Toribio

J. Milia en plaque in a bilateral submandibular distribution. Clin Exp Dermatol. 1998 Sep. 23(5):227-9. 3. Castelvetere M. Milia en plaque. J Eur Acad Dermatol Venereol. 1999 Mar. 12(2):195-6. 4. Garcia Sanchez MS, Gomez Centeno P, Rosen E, Sanchez-Aguilar D, Fernandez-Redondo V, Toribio

J. Milia en plaque in a bilateral submandibular distribution. Clin Exp Dermatol. 1998 Sep. 23(5):227-9. 5. Ratnavel RC, Handfield-Jones SE, Norris PG. Milia restricted to the eyelids. Clin Exp Dermatol. 1995

Mar. 20(2):153-4. 6. Charles M G Archer, MBBS, MRCP(UK) Milia Clinical Presentation. Updated: Mar 10, 2017 https:// emedicine.medscape.com/article/1058063-clinical#b3 [accessed 16.01.19]. 7. Calabrese P, Pellicano R, Lomuto M, Castelvetere M. Milia en plaque. J Eur Acad Dermatol Venereol. 1999 Mar. 12(2):195-6. 8. Miller LM, Schwartz JT, Cho S. Milia: a unique reaction to tattoos. Cutis. 2011 Apr. 87(4):195-6. 9. Connelly T. Eruptive milia and rapid response to topical tretinoin. Arch Dermatol. 2008 Jun. 144(6):816-7. 10. Berk D, Bayliss S, Milia: A review and classification, Journal of the American Academy of

Dermatology, December 2008 11. Garcia Sanchez MS, Gomez Centeno P, Rosen E, Sanchez-Aguilar D, Fernandez-Redondo V, Toribio

J. Milia en plaque in a bilateral submandibular distribution. Clin Exp Dermatol. 1998 Sep. 23(5):227-9. 12. Calabrese P, Pellicano R, Lomuto M, Castelvetere M. Milia en plaque. J Eur Acad Dermatol Venereol. 1999 Mar. 12(2):195-6. 13. Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol. 1997 Aug. 37(2 Pt 2):353-6. 14. Multiple eruptive milia in a 9-year-old boy. Diba VC, Handfield-Jones S, Rytina E, Hall P, Burrows N

Pediatr Dermatol. 2008 Jul-Aug; 25(4):474-6. 15. Review Multiple eruptive milia: report of a case, review of the literature, and a classification. Langley

RG, Walsh NM, Ross JB J Am Acad Dermatol. 1997 Aug; 37(2 Pt 2):353-6 16. Rutter KJ, Judge MR. Profuse congenital milia in a family. Pediatr Dermatol. 2009 Jan-Feb. 26(1):62-4. 17. Heard MG, Horton WH, Hambrick GW Jr. The familial occurrence of multiple eruptive milia. Birth

Defects Orig Artic Ser. 1971 Jun. 7(8):333-7. 18. Graham-Brown R, Burns T, Dermatology, Lecture Notes, Wiley Blackwell, 10th Edition, 2011 19. George DE, Wasko CA, Hsu S. Surgical pearl: evacuation of milia with a paper clip. J Am Acad

Dermatol. 2006 Feb. 54(2):326. 20. Sandhu K, Gupta S, Handa S. CO2 laser therapy for Milia en plaque. J Dermatolog Treat. 2003 Dec. 14(4):253-5. 21. Noto G, Dawber R. Milia en plaque: treatment with open spray cryosurgery. Acta Derm Venereol. 2001 Oct-Nov. 81(5):370-1. 22. The Primary Care Dermatology Society (PCDS), <http://www.pcds.org.uk/> 23. Kluk J, Understanding Retinol Tolerance, Aesthetics journal, December 2018 < https:// aestheticsjournal.com/feature/understanding-retinol-tolerance>