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Spot on Milia

By: Risa Caldoza-De Leon MD, FPAPSHPISpot on Milia

For a newborn baby, having milia on your face is par for the course. But at 36 years old, it might be a cause for worry. Jenny came to me for consult asking if it were normal for an adult to have milia. “My kids had them when they were babies but those pesky spots disappeared over time. It’s irritating that I suddenly saw my forehead spotted too. I initially thought they were whiteheads that just popped up. It’s so ugly doc, I can see it through my makeup,” she wailed.

A milium (milia when they are many), is a tiny, about 1-2 mm, raised pearly-white or yellowish hard dome-shaped bump that develop when tiny skin flakes are trapped in small pockets near the surface of the skin. A milium is formed at the base of a hair follicle or sweat gland.  It is a type of tiny skin cyst filled with a protein called keratin. Keratin is a natural part of the skin, also found in nails and hair. The term “milium” hails from the mid-19th-century Latin word “millet” because of it does look like a millet seed. It is also called a milk spot or an oilseed.

Milia are common in all ages, of any ethnicity, and both sexes. These little globs of protein can be seen across the nose, chin or cheeks, eyes and eyelids, forehead and sometimes in the upper trunk and limbs. When these bumps are seen on a baby's gums or roof of the mouth, they become known as Epstein pearls; in the palate, they are called Bohn nodules. Epstein pearls are seen in 85% of infants. These bothersome and unsightly yet benign bumps can last for weeks, months, or longer.

I explained to Jenny, “Don’t despair, they may be ugly to look at but they’re completely harmless. Your skin’s natural exfoliation process just malfunctioned. Milia are proteins trapped within the skin, while whiteheads are fats and skin debris trapped within the pore.” Milia does not usually cause any symptoms but some people complain that they itch. They do not cause permanent scarring such as can occur from certain types of acne. Unlike some skin conditions, they don't seem to be linked to diet or lifestyle.

There are several types of milia. These are:

  • Neonatal milia affect half of newborn babies. They favor the nose area and are said to arise from sweat glands that aren't fully developed or mature. Half of all babies develop neonatal milia, so fear not.
  • Juvenile milia caused by genetic disorders such as nevoid basal cell carcinoma syndrome.
  • Primary milia can be seen in both children and adults.
  • Secondary milia develop in any area that has been previously damaged, such as after a burn, blistering disorders, or after skin creams have been applied. This type can become permanent.

The changes in the skin that happen from years of chronic sun damage seem to promote milia formation for some. Also, according to some studies, the active ingredients of sunscreens like Parsol 1789 may cause allergies that may lead to a milia breakout.

  • Milia en plaque is a rare type where the milia can be seen atop a raised patch of skin. The cysts can be several centimeters in diameter. It usually occurs behind the ears, on an eyelid, or on the cheeks or jaw area, particularly of middle-aged women. It’s sometimes associated with other skin diseases including lupus erythematosus and lichen planus.
  • Multiple eruptive milia pop out in crops or patches and develop over time (weeks or months). Although very rare, when they do occur, they appear on the face, the upper arms, and the upper trunk. This occurs more frequently in women.

There are no tests necessary for the diagnosis of milia because of its characteristic appearance. However, in certain cases, a skin biopsy may be recommended to tell the difference between milia and harmful skin conditions.

In the time of Christ, Cornelius Celsius, a Roman encyclopedist, wrote in his medical book De Medicina:  “To treat pimples and spots and freckles is almost a waste of time, yet women cannot be torn away from caring for their looks.”

Although milia typically disappear and clear on their own within several weeks or months, medical treatment may be warranted for persistent cases. So, if waiting it out is not an option, it’s time to call on your skin care physician.

We can remove milia using a fine sterile needle or lancet, then squeezing, or pricking out the contents using a comedone extractor. We call this deroofing. This is a medical procedure because any puncture of the skin creates the risk of infections. Please do not do this at home! When improperly done, this can traumatize your skin, leaving dark marks (hyperpigmentation) or even permanent scars.

When widespread and persistent, these are some forms of treatment:

  • Cryotherapy
  • Laser treatment
  • Dermabrasion
  • Chemical peeling
  • Destruction curettage (surgical scraping and cauterization)
  • Retinoid creams (creams that contain vitamin A compounds)
  • Oral antibiotic tablets like minocycline, especially for milia en plaque

For Jenny, I treated her with regular monthly deep cleansing facials with extraction and gently microdermabrasion. I also did a targeted exfoliating treatment with salicylic acid monthly for three consecutive months. I gave her maintenance mild cleanser, a very good toner, a moisturizer and sunblock, SPF 50. A solid daily facial routine with sun protection is a must – milia or not! Jenny has long said goodbye to her milia.

Remember that nothing absolutely prevents milia from forming if you're prone to them. But for babies and adults alike, the Mayo Clinic gives these tips:

  • Keep face clean. Wash face daily with warm water and mild soap.
  • Dry face gently. Simply pat dry.
  • Do not try to squeeze them out. You will just make matters worse from the trauma.
  • Don't pinch or scrub the bumps. This might irritate or infect the skin.
  • Avoid using lotions or oils on your baby's face.
  • Exfoliate. Adults should do regular gentle exfoliation to slough away dead skin cells on the skin’s surface
  • Use sunscreen of at least SPF. Sun damage thickens skin, making it prone to clogging of the pores with oil and debris.
  • Avoid heavy makeup.
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