How to treat milia?

Treatment of Milia

The most effective treatment for milia is mechanical extraction using a sterile needle or lancet followed by gentle expression of the cyst contents. This direct approach provides immediate cosmetic improvement with minimal risk of scarring when performed properly.

Understanding Milia

Milia are small, benign, white keratinous cysts measuring 1-4 mm that appear as pearly white papules on the skin 1. They can be classified as:

• Primary milia: Spontaneously arising, commonly seen in neonates or adults
• Secondary milia: Occurring after skin trauma, dermatological procedures, or in areas of bullous eruptions 2
• Multiple eruptive milia (MEM): A rare variant characterized by sudden onset of numerous milia 1, 3
• Milia en plaque: Rare type presenting as erythematous plaques studded with milia 4

Treatment Algorithm

First-line treatments:

1. Mechanical extraction

   • Create a small opening with a sterile needle or lancet
   • Gently express contents with a comedone extractor
   • Most effective for isolated lesions
   • Provides immediate results

2. Topical retinoids

   • Apply tretinoin 0.025-0.05% cream nightly
   • Helps accelerate turnover of epidermal cells
   • May take several weeks to show results
   • Best for multiple lesions or prevention

Second-line treatments:

1. Electrodesiccation

   • Light electrocautery to create an opening in the cyst
   • Followed by expression of contents
   • Useful for resistant or recurrent milia

2. Cryotherapy

   • Brief application of liquid nitrogen
   • May require multiple sessions
   • Risk of hypopigmentation, especially in darker skin types

3. Microdermabrasion

   • Mechanical exfoliation of the epidermis
   • May help with widespread milia
   • Multiple sessions typically required

For extensive or resistant cases:

1. Laser therapy

   • CO2 or Er:YAG laser for precise ablation
   • Higher cost but effective for multiple lesions
   • Requires specialized equipment and training

2. Chemical peels

   • Superficial peels with glycolic or salicylic acid
   • May require multiple treatments
   • Best for widespread milia

Special Considerations

• Neonatal milia: Usually resolve spontaneously within the first few months of life without intervention 5
• Congenital milia: May be associated with inherited disorders in some cases 5
• Secondary milia: May develop in areas of previous skin trauma or in herpes zoster scars 2
• Multiple eruptive milia: More challenging to treat due to extensive distribution 3

Pitfalls to Avoid

• Aggressive extraction: Can lead to scarring or infection
• Self-extraction: Patients should be advised against attempting home removal
• Misdiagnosis: Ensure proper diagnosis, as other conditions like closed comedones, syringomas, or molluscum contagiosum may appear similar
• Overlooking underlying causes: In cases of sudden eruption of multiple milia, consider potential triggers like trauma or medication

Prevention Strategies

• Regular gentle exfoliation with alpha hydroxy acids
• Proper cleansing to prevent buildup of keratin
• Avoidance of heavy, occlusive cosmetics
• Maintenance therapy with topical retinoids for recurrent cases

For milia en plaque, a combination approach using minocycline and manual expression has been reported as successful 4, though this specific presentation is rare and may require dermatologist management.