What is the best treatment for milia?

Treatment Options for Milia

The most effective treatment for milia is extraction or incision with a needle or blade, followed by topical retinoids for prevention of recurrence. 1, 2

What Are Milia?

Milia are benign, small, white, keratinaceous cysts that present as fine white papules on the skin. They can be classified as:

• Primary milia: Occur spontaneously without preceding skin damage 3
• Secondary milia: Result from skin trauma or disease 3
• Multiple eruptive milia (MEM): Characterized by sudden eruption of numerous milia, typically on the head, neck, and trunk 2
• Milia en plaque: A rare variant presenting as grouped milia on an erythematous base 4

Treatment Approaches

First-Line Treatments

• Mechanical extraction:

  • Using a sterile needle or blade to create a small opening, followed by gentle expression of the cyst contents 2
  • Most effective for isolated lesions or small numbers of milia 3
  • Can be performed in-office with minimal scarring risk 2

• Topical retinoids:

  • Tretinoin has shown success in treating milia, particularly milia en plaque 1
  • Works by increasing cell turnover and preventing keratin accumulation 1
  • Particularly useful for multiple lesions or prevention of recurrence 2

Second-Line Treatments

• Electrodesiccation:

  • Using light electrocautery to create an opening in the cyst 2
  • Effective for multiple lesions that are resistant to other treatments 3

• Cryotherapy:

  • Application of liquid nitrogen to destroy the cyst wall 2
  • May cause hypopigmentation, especially in darker skin types 3

• Microdermabrasion:

  • Mechanical exfoliation to remove the superficial layer of skin 2
  • Can help with widespread milia 3

Special Considerations

• Milia en plaque:

  • This rare variant is more challenging to treat 4
  • Topical tretinoin has shown success in pediatric cases 1
  • May require combination therapy with extraction and retinoids 4

• Multiple eruptive milia:

  • This rare condition may require more aggressive treatment 2
  • Consider combination approaches with both physical removal and topical treatments 3

Treatment Algorithm

1. For isolated or few milia:

   • Begin with mechanical extraction using a sterile needle or blade 2
   • Apply topical retinoids afterward to prevent recurrence 1

2. For multiple or widespread milia:

   • Consider starting with topical retinoids (tretinoin) 1
   • For resistant cases, add mechanical extraction of larger lesions 2
   • For very extensive cases, consider electrodesiccation or microdermabrasion 3

3. For milia en plaque:

   • Begin with topical tretinoin 1
   • Add mechanical extraction for prominent lesions 4
   • Consider more aggressive approaches if resistant to treatment 4

Practical Tips

• Avoid squeezing or attempting home extraction without proper tools, as this may lead to scarring 2
• Consistent use of topical retinoids is key for prevention of recurrence 1
• Milia can occur in unusual locations such as the vulva, requiring the same treatment approaches 5
• Patient education about the benign nature of these lesions is important to reduce anxiety 3