Dermatology Online Journal

Multiple eruptive milia
Priya Batra MD, Hui C Tsou MD, Melanie Warycha MD, Henry J Votava MD, Jennifer Stein MD PhD
Dermatology Online Journal 15 (8): 20

Department of Dermatology, New York University

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Abstract

A 61-year-old-man presented with a sudden onset of multiple, hyperpigmented papules with a central punctum on the face, chest, upper back, and arms. Histopathologic examination showed infundibular cysts. These findings are consistent with a diagnosis of multiple eruptive milia, which is a rare disorder that is characterized by the sudden development of crops of milia over weeks to months. They are more extensive in number and distribution than they are in primary milia. Milia may present spontaneously without a known cause, as part of an inherited familial condition, or as part of a genodermatosis. The etiologies are uncertain, and treatment options are varied.

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Figure 1	Figure 2

History

A 61-year-old man presented to the Dermatology Clinic at the Veterans Affairs New York Harbor Healthcare System in July, 2008, for the evaluation of a papular eruption on his upper trunk, arms, and face, with a sudden and rapid onset. The lesions were initially pruritic but were asymptomatic at the time of the examination. He denied fevers, chills, or weight loss. There was no personal or family history of similar lesions nor was there a history of acne or trauma. After a biopsy was performed and the diagnosis was determined, he was treated with oral doxycycline and topical clindamycin solution with minimal benefit. The treatment was then changed to topical tretinoin cream, manual extraction of lesions, and intralesional injections of triamcinolone acetonide without much success. He continued to develop new lesions with residual scars at sites of his older lesions. He has been unable to identify any trigger for the development of this eruption.

The medical history includes hypertension and hepatitis C virus infection. His only medication is atenolol. He does not use alcohol and smokes a few cigarettes daily.

Physical Examination

Multiple, hyperpigmented papules, some with a central punctum, were located on the face, chest, upper back, and arms. There were also scattered, hyperpigmented macules and crateriform scars.

Laboratory data

The hepatitis C genotype Ia viral load was > 2,000,000 copies/mL. Alpha fetal protein was normal at 6.4 ng/mL. A complete blood count, basic metabolic panel, liver function panel, and thyroid stimulating hormone were normal. A human immunodeficiency virus test was negative.

Histopathology

Within the superficial dermis, there is a small cyst that is lined by stratified squamous epithelium with a granular layer which contains eosinophilic concentric lamellae of keratin.

Comment

Milia are benign superficial keratinous cysts, which on histopathologic examination appear as small infundibular cysts that are lined with stratified squamous epithelium, which contain a granular-cell layer. Primary milia spontaneously arise from the sebaceous collar of the lower infundibulum of the hair follicle. They are present at birth in up to 50 percent of newborns and are found in older children and adults around the eyelids, cheeks, forehead, and genitalia. Alternatively, secondary milia commonly arise from eccrine ducts and are associated with disease, medication, or trauma [1, 2]. Although milia are frequently encountered in clinical practice, these benign skin lesions may have unusual presentations and rare syndromic associations.

Multiple eruptive milia is a rare skin disorder that is characterized by the sudden development of crops of milia over weeks to months, which are more extensive in number and distribution than they are in primary milia. [1, 2, 3]. Cases have been reported among patients aged 15 to 71 years, with lesions favoring the face, upper arms, chest, and upper back. The lesions are usually asymptomatic. In 1997, a classification was proposed to encompass reported cases of multiple eruptive milia [3]. According to this classification, milia could either present spontaneously without known cause, as part of an autosomal dominant familial condition, or as part of a genodermatosis, such as Rombo syndrome, basaloid follicular hamartoma syndrome, or Gardner syndrome [4].

The etiology of multiple eruptive milia is uncertain. Published case reports have identified different and unique precipitants. For instance, in a 71-year-old man with diabetes mellitus and diabetic nephropathy, who developed multiple milia, it was thought that chronic renal failure may have been a contributing factor as renal failure leads to other follicular eruptions, such as perforating disorders [3]. Another patient with a renal transplant on cyclosporin immunosuppression was thought to have multiple milia that were associated with cyclosporin use [5]. Because of the distribution on the face and upper trunk, sunlight has been suggested as a possible etiology [6]. Other reported cases have failed to identify any type of causative factor [4, 7, 8].

There is no standardized treatment for this condition. Milia may spontaneously clear without treatment after several months. Incision, curettage, and electrodesiccation are effective yet may be considered impractical due to the number of lesions and associated patient discomfort. Topical retinoids, oral retinoids, and minocycline have been successfully utilized for milia en plaque, but their use has not been studied in multiple eruptive milia. One case report showed possible benefit from the use of oral azithromycin [10], and another showed benefit with use of topical tretinoin [9], with clearing of all lesions within six weeks.

References

1. Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol 2008;59:1050 [PubMed]

2. Wolfe SF, Gurevitch AW. Eruptive milia. Cutis 1997; 60:183 [PubMed]

3. Langley RG, et al. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol 1997;37:353 [PubMed]

4. Diba VC, et al. Multiple eruptive milia in a 9-year-old boy. Pediatr Dermatol 2008;25:474 [PubMed]

5. Schoendorff C, et al. Multiple epidermoid cysts in a renal transplant recipient taking cyclosporine A. Cutis 1992;50:36 [PubMed]

6. Rasmussen JE. A syndrome of trichoepitheliomas, milia, and cylindromas. Arch Dermatol 1975;111:610 [PubMed]

7. Cairns ML, Knable AL. Multiple eruptive milia in a 15-year-old boy. Pediatr Dermatol 1999; 16:108 [PubMed]

8. Diba VC, et al. A case of eruptive milia. Clin Exp Dermatol 2005;30:677 [PubMed]

9. McCarley O'Shea E, et al. Azithromycin therapy for multiple eruptive milia: a report of a case, new treatment option, and review of the literature. Internet J Dermatol 2009;7:1

10. Connelly T. Eruptive milia and rapid response to topical tretinoin. Arch Dermatol 2008;144:816 [PubMed]

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