Dermatology Online Journal

Letter: Periorbital bilateral milia en plaque in a female teenager
P Boggio¹ MD, R Alperovich¹ MD, R E Spiner¹ MD, R Schroh² MD, M Hassan¹ MD
Dermatology Online Journal 18 (4): 11

1. Dermatology Department, Ramos Mejía Hospital, Buenos Aires, Argentina
2. Dermatopathology Department, Ramos Mejía Hospital, Buenos Aires, Argentina

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Abstract

We present the case of a 16-year-old girl with a 2-year history of progressive development of milia en plaque of the eyelids.

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Case synopsis

A healthy sixteen-year-old female patient presented with multiple periorbital papules with a bilateral distribution. She denied any previous local trauma or the use of topical corticosteroids or occlusive make up. She had no history of burns or radiotherapy. Personal and familiar history was unremarkable.

Figure 1	Figure 2
Figure 1. Bilateral periocular tiny yellowish papules on a discrete erythematous base, affecting predominantly the upper eyelids Figure 2. Several keratin-filled cysts surrounded by a moderate lymphocytic inflammatory infiltrate in the up-middle dermis (H&E, x45)

Examination revealed multiple yellowish periocular milia, varying in size from 1 to 3 mm, scattered on a discrete erythematous base, affecting predominantly both upper eyelids (Figure 1). The papules were asymptomatic and had slowly increased in number and size since they had appeared two years previously. The remaining physical examination was uneventful.

A skin biopsy showed several dermal keratin-filled cysts, surrounded by a moderate lymphocytic inflammatory infiltrate (Figure 2). A granulomatous reaction with isolated giant cells of the foreign body type was observed in some areas.

The patient received oral minocycline with a daily dose of 100 mg combined with monthly local applications of a 30 percent solution of trichloroacetic acid. After three months on this regimen, it was discontinued because there was no improvement.

Milia are clinically recognized as small white to yellow papules that histologically correspond to keratin cysts [1]. Primary milia are considered proliferative lesions and arise spontaneously from the infundibula of vellus hair follicles and sebaceous glands; secondary milia represent retention cysts that erupt after local trauma – on normal or previously diseased skin; these are probably derived from eccrine sweat ducts or hair follicles [1, 2].

Milia en plaque (MEP) – first described by Balzer and Bouquet in 1903, and named by Hubler et al in 1978 – is an uncommon variant of primary milia that consists of grouped milia on an erythematous background [1, 3]. It generally affects middle-aged women and has no predilection for race. The region more commonly involved is the retrouricular area, followed by the supraclavicular, submandibular, and ocular locations; there may be unilateral or bilateral distribution [1].

Clinically MEP presents with a variable number of minuscule milia within an erythematous plaque. The eruption is usually asymptomatic. Histopathological findings consist of cysts, lined by a thin stratified squamous epithelium, that contain orthokeratotic-laminated keratin [1, 3]. Pericystic lymphocytic infiltration is a rare feature of single milia but a frequent aspect of MEP, and probably correlates with the presence of erythema.

The occurrence of MPE in childhood or adolescence is extremely rare, with seven cases reported among children [3-7]. Unilateral distribution in periocular location is the most common presentation. Amongst the seven pediatric MEP described, five were periocular (one bilateral and four cases with unilateral distribution) [3, 5, 6, 7].

Although a benign disorder, MEP represents a cosmetic concern [1]. Therapeutic modalities comprise mainly several destructive techniques. They include manual extraction, topical tretinoin or trichloroacetic acid, which are preferred when the inflammatory infiltrate is mild and lesions are limited to the superficial dermis.. Electrodessication, cryosurgery, dermabrasion, photodynamic therapy, or CO2 laser may be desirable when inflammation is severe and cysts are deeper. For those deeper and inflammatory MEP, oral minocycline could also be helpful because of its anti-inflammatory properties [1-7]. All these therapeutic methods provide aesthetic improvement but not complete remission.

This MEP case occurred in an adolescent female, had a bilateral distribution in the periocular area, and was unresponsive to combined treatment with topical trichloroacetic acid and oral minocycline.

References

1. Wong SS, Goh CL. Milia en plaque. Clin Exp Dermatol 1999;24(3):183-5. [PubMed]

2. van Lynden-van Nes AM, der Kinderen DJ. Milia en plaque successfully treated by dermabrasion. Dermatol Surg 2005;31(10):1359-62. [PubMed]

3. Bridges AG, Lucky AW, Haney G, Mutasim DF. Milia en plaque of the eyelids in childhood: case report and review of the literature. Pediatr Dermatol 1998;15(4):282-4. [PubMed]

4. Lee DW, Choi SW, Cho BK. Milia en plaque. J Am Acad Dermatol 1994;31(1):107. [PubMed]

5. Bouassida S, Meziou TJ, Mlik H, Fourati M, Boudaya S, Turki H, et al. Childhood plaque milia of the inner canthus. Ann Dermatol Venereol 1998;125(12):906-8. [PubMed]

6. Dogra S, Kanwar AJ. Milia en plaque. J Eur Acad Dermatol Venereol 2005;19(2):263-4. [PubMed]

7. Cota C, Sinagra J, Donati P, Amantea A. Milia en plaque: three new pediatric cases. Pediatr Dermatol 2009;26(6):717-20. [PubMed]

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