Treatment of Small Milia on the Upper Eyelid
For a small milia on the upper eyelid, the most effective treatment is simple mechanical extraction using a sterile needle or blade to create a small opening followed by expression of the keratin-filled cyst contents, which can be performed in-office by a dermatologist or ophthalmologist.
Understanding Milia on the Eyelid
Milia are benign, superficial keratin-filled epidermoid cysts that appear as small white papules 1. When occurring on the eyelid, they are typically primary (spontaneous) rather than secondary to trauma 1. While eyelid involvement is less common than other facial sites, isolated upper eyelid milia have been documented 2, 3.
Primary Treatment Approach
Mechanical Extraction (First-Line)
- Direct extraction is the definitive treatment: A sterile needle or fine blade is used to create a small opening in the cyst, followed by gentle expression of the keratin contents 1
- This procedure is quick, effective, and can be performed in an outpatient setting without significant risk of scarring when done properly 1
- The procedure should be performed by an experienced clinician (dermatologist or ophthalmologist) given the sensitive periocular location 2
Conservative Management (For Observation)
- If the milia is truly asymptomatic and the patient prefers observation, watchful waiting is reasonable as milia are entirely benign 4
- However, most patients seek treatment for cosmetic concerns 4
Alternative Treatment Options
Topical Retinoids
- Topical tretinoin can be effective for milia, particularly in cases of milia en plaque (multiple clustered milia) 5
- This approach requires weeks to months of consistent application and may cause irritation in the periocular area 5
- Caution: Retinoids near the eye require careful application to avoid ocular irritation 5
Laser Treatment
- CO2 fractional laser can be used for multiple or recurrent eyelid milia, providing superficial ablation with minimal thermal damage 4
- This is typically reserved for extensive cases (milia en plaque) rather than a single small lesion 4
- Results show minimal scarring and rapid recovery, though multiple treatments may be needed 4
Important Clinical Considerations
What to Avoid
- Do not confuse milia with other eyelid lesions: Ensure proper diagnosis before treatment, as other conditions (hordeolum, chalazion, or malignancies) require different management 6, 7
- Warm compresses and eyelid hygiene (appropriate for hordeolum/stye) are ineffective for milia, as these are keratin-filled cysts rather than inflammatory or infectious processes 6
When to Refer
- Refer to ophthalmology or dermatology if you are uncomfortable performing periocular procedures 2
- Consider biopsy if the lesion appears atypical or if there is diagnostic uncertainty, particularly to rule out malignancy in older patients 7
- Multiple eruptive milia or milia en plaque may warrant dermatology referral for consideration of underlying genodermatosis 1