What is the diagnosis and treatment for a female patient with multiple white, creamy-colored bumps on her face, particularly along the eye line, cheeks, and jaw, with a small indurated area in the center resembling a pore, suggestive of milia?

Diagnosis and Management of Facial Milia

The diagnosis is milia, and the recommended treatment is physical removal through incision and extraction, electrodesiccation, or CO₂ laser vaporization, with laser therapy showing excellent results for multiple lesions.

Clinical Diagnosis

Your clinical assessment is correct—these white, creamy-colored bumps with a small central indurated area resembling a pore are characteristic of milia 1. Milia are small (1-4 mm), benign keratinous cysts that commonly occur on the face, particularly around the eyes, cheeks, and jawline 2.

Diagnostic Considerations

• Rule out other conditions: While your clinical description strongly suggests milia, consider distinguishing from:

  • Seborrheic keratoses (though these typically appear more pigmented and raised) 3
  • Molluscum contagiosum (which would have central umbilication and viral shedding) 4
  • Any pigmented lesions should be evaluated for melanoma if there is change in size, shape, or color 3

• Identify the milia variant: Multiple facial milia can represent:

  • Primary milia (spontaneous, most common)
  • Multiple eruptive milia (sudden onset, mainly head/neck/trunk) 2
  • Milia en plaque (milia on erythematous edematous base) 5
  • Secondary milia (post-trauma, post-bullous disease, or associated with lichen sclerosus) 4, 6

Treatment Approach

For multiple facial milia, CO₂ laser vaporization is highly effective and provides the best cosmetic outcome 7:

• CO₂ laser parameters: Use superpulsed and focused mode at 2 W/cm², with two passes per session 7
• Expected outcomes: Marked improvement after a few sessions with minimal side effects and no recurrence in 12-36 month follow-up 7
• Advantages: Particularly effective for multiple lesions or milia en plaque variants, with good cosmetic results in both adults and children 7

Alternative treatment options include:

• Incision and curettage: Aggressive enough to cause bleeding for complete removal 4
• Simple excision with cautery 4
• Cryotherapy 4

Important Clinical Pitfalls

• Avoid biopsy for typical milia: These are benign lesions with characteristic clinical appearance; biopsy is unnecessary and may cause scarring 1
• Do not use laser on suspicious pigmented lesions: If any lesion appears atypical or pigmented, complete excision with a surgical knife (not laser) is required to preserve tissue for histological examination 8, 3
• Assess for underlying conditions: Secondary milia may indicate previous bullous disease, trauma, or genodermatoses 1, 6

Follow-Up

• Milia are cosmetically troublesome but benign 2
• Recurrence after proper treatment is uncommon 7
• No follow-up is necessary after successful removal unless new lesions develop 4