Milia: A review and classification

Evaluation and management of benign tumors of the eye and eyelid

Benign tumors of the eye and eyelid are common in children and adults, and they rarely undergo malignant transformation. Their workup and management have evolved over the years with increasing advancements in surgical and laser therapies. This contribution focuses on describing the following benign eye and eyelid tumors and their diagnostic and treatment approaches: congenital and acquired melanocytic nevi; nevus of Ota (Hori nevus); conjunctival papilloma; seborrheic keratosis; epidermoid cyst; dermoid cyst; milium; xanthelasma; hemangioma (cherry angioma and pyogenic granuloma); neurofibroma; neurilemmoma (schwannoma); and fibroepithelial polyp. Surgical removal is the primary treatment approach for many of these benign tumors. With advancements in laser technologies, there are now several laser types that can be used in the treatment of these benign eye and eyelid tumors. Other treatment modalities include cryosurgery, electrosurgery, and topical or intralesional medications. We hope this review will provide a reference to dermatologists and ophthalmologists in their approach to evaluation and management of benign eye and eyelid tumors.

Benign Cutaneous Cysts: A Comprehensive Analysis of 1160 cases

Background Cysts are common skin abnormalities that are mostly benign; however, sometimes malignant lesions may present clinically as cystic manifestations. Benign cutaneous cysts can be of different morphological types and their diagnosis relies on histological evaluations. The most common mode of treatment is surgical excision, which is curative. Methodology This is a retrospective cross-sectional study conducted at the Department of Histopathology, Chughtai Institute of Pathology, Lahore, Pakistan from 1st January 2020 to 31st December 2022. Non-probability consecutive sampling was done, and all the cases of benign cutaneous cysts were included. All cases were microscopically reviewed by two histopathologists, and variables like age, gender, site of the lesion, and histological diagnosis were noted. The data were analyzed using IBM SPSS Statistics for Windows, Version 29 (Released 2022; IBM Corp., Armonk, New York, United States). Results A total of 1160 recorded cases of benign cutaneous cysts were included. Overall gender distribution revealed males (n=489, 42.1%) and females (n=671, 57.8%). The age range was 3 to 91 years with a mean age of 37.56 ± 16.05 years. The three most common cysts were epidermal inclusion cysts (74.3%), trichilemmal cysts (15.1%), and dermoid cysts (6.3%). Other cysts were uncommon including hidrocystoma (1.9%), steatocystoma (0.3%), verrucous cysts (0.3%), comedones (0.6%), hybrid cysts (0.2%), milia (0.3%), and vellus hair cysts (0.2%). The most common site was back (23.5%) for epidermal inclusion cysts, scalp (74.4%) for trichilemmal cysts, and eye (33.8%) for dermoid cysts. Conclusion Benign cutaneous cysts have a broad morphological spectrum with a wide age range. Epidermal inclusion cysts, trichilemmal cysts, dermoid cysts, and hidrocystoma account for the four most common types. For each of the other cyst type, the prevalence was under 1%. Female gender predominated in epidermal inclusion cysts, trichilemmal cysts, and dermoid cysts while male gender was common in other cysts. Overall majority of the cysts presented in the head and neck area.

Ultrasonographic Spectrum of Cutaneous Cysts With Stratified Squamous Epithelium in Pediatric Dermatology: Pictorial Essay

High-resolution ultrasound (HRUS) is an important diagnostic method in dermatology, especially in pediatric population. The most common type of cutaneous cysts in children corresponds to cysts with stratified squamous epithelium (CSSE). The objective is to present the different ultrasonographic appearance of histologically proven CSSE in a retrospective review. Epidermoid, milium, trichilemmal, dermoid, and pilonidal cyst and steatocystomas are included. Utility of HRUS in diagnosis of cutaneous lesions is well established. It is important to know-and stay updated-about the wide spectrum of ultrasonographic appearance of CSSE in order to avoid misleading diagnoses.

Segmental infantile hemangioma with milia: A case report

Milia are common in children. They are small, keratinizing cysts that arise either as primary epidermoid cysts or secondary to other dermatoses, trauma or certain medications. In the paediatric population, milia are most frequently congenital and resolve spontaneously. Infantile hemangiomas are relatively common in neonates. They typically arise within the first few weeks of life, undergo a proliferative phase in the first 6 months, then begin to involute at around 12 months of age. After involution, residual skin changes may be observed, such as telangiectasia, fibrofatty tissue and redundant skin. However, there is a gap in the literature regarding concomitant milia and infantile hemangiomas. We report a case of a 5-months-old female who presented with a large, segmental infantile hemangioma of the posterior neck with milia.

Primary Localized Cutaneous Nodular Amyloidosis Presenting as Milia: An Unusual Clinical Manifestation

Primary localized cutaneous nodular amyloidosis (PLCNA) is rare and clinically noncharacteristic, presenting mostly as plaque-like lesions. We report a case of a progressively larger erythematous plaque following a contusion of the skin on the right zygomatic area, which was strangely covered with recurrent scattered 2 mm whiteish blisters to the extent that it was misdiagnosed as a herpesvirus infection several times over a decade. Pathology and special staining diagnosed nodular amyloidosis with milia.

Oral-Facial-Digital Syndrome Type 1: A Case Report and Review

Oral-facial-digital syndrome type 1 (OFD1), first described by Papillon-Léage in 1954, is transmitted as an X-linked dominant condition and is characterized by a combination of malformations in the face, oral cavity, and digits. Malformations of the brain and polycystic kidney disease are also commonly associated with OFD1. An 11-month-old female presented with multiple tiny whitish papules on her face that had been present since birth. The histopathologic examination was consistent with milium. She also had congenital anomalies, including incomplete cleft palate, bifid tongue, short frenulum, anomalous deformities of both toes, and clino-brachy-syndactyly. Based on the characteristic dysmorphic features of her face, mouth, and hands, a clinical diagnosis of OFD1 was made. Herein, we report a rare case of OFD1 featuring congenital milia, which has not been previously reported in the Korean literature.

Neonatal Dermatology: The Normal, the Common, and the Serious

The objective of this review is to help practitioners of neonatal and pediatric medicine become more familiar with diagnosing and managing neonatal skin conditions. This article will discuss normal neonatal skin care and benign and common rashes, as well as some of the serious dermatologic conditions that require specialists for further evaluation and/or treatment.

Multiple milia formation in blistering diseases

BACKGROUND

Milia are superficial keratinous cysts seen as pearly white, dome-shaped lesions 1-2 mm in diameter. Milia are associated with diseases that cause subepidermal blistering, such as hereditary forms of epidermolysis bullosa, epidermolysis bullosa acquisita, bullous pemphigoid, bullous lichen planus, and porphyria cutanea tarda. Multiple eruptive milia are rare and more extensive in number than primary milia.

OBJECTIVE

The aim of this study was to search the literature for cases of blistering diseases with multiple milia formation, especially in areas of the skin where there was no evidence of blistering or trauma, and review the interpretations of their pathogenesis.

METHODS

We performed a literature search with the terms multiple milia and bullous diseases, pemphigoid, and pemphigus.

RESULTS

Very few studies have investigated the origin of milia. Primary milia are thought to originate from the sebaceous collar of vellus hairs, and secondary milia are believed to derive from eccrine ducts more commonly than from overlying epidermis, hair follicles, or sebaceous ducts. Milia secondary to blisters or trauma are speculated to be produced through the regeneration process of disrupted sweat glands or hair follicles. Immunological predisposition, aberrant interaction between the hemidesmosomes, and the extracellular matrix components beneath the hemidesmosomes have been described with regard to the formation of numerous milia during recovery. Multiple milia could be a primary manifestation of dystrophic epidermolysis bullosa in skin areas without evidence of blistering.

CONCLUSION

The exact etiology of multiple milia remains unknown. Immunological predisposition and improper interaction between hemidesmosomes and extracellular matrix components are speculated to play a role in the formation of milia during recovery of bullous lesions in blistering diseases. Still, further studies on the triggering mechanisms of keratinocyte dysfunction in cases of multiple milia formation without evidence of prior blistering are needed.

Unusual Location for a Periorbital Dermoid Cyst

Dermoid cysts in the orbit classically present in children as a mass in the superotemporal or superonasal orbit along the zygomatico-frontal or fronto-ethmoidal suture lines. The presence of a dermoid cyst in the superficial eyelid, not associated with the tarsus, has only been reported once previously. The authors present a case of a 60-year-old man with a painless right lower eyelid mass inferonasally that was completely excised and found to be a dermoid cyst. The presence of a dermoid cyst involving the superficial lower eyelid is very rare. Furthermore, dermoid cysts in adults typically present in the setting of trauma, which was absent in this case. Therefore, it is important to consider dermoid cysts in the differential diagnosis of eyelid lesions in adults.

What should a cosmetologist know about dermatological lesions on the face?

In everyday practice, cosmetologists often observe abnormalities on the facial skin of his or her clients. Facial lesions have a diverse clinical picture, although most are benign. However, some lesions may be malignant and demand fast diagnosis and treatment. Among benign lesions are xanthomas, epidermal cysts, milia and seborrheic keratoses. Xanthomas are usually localized on the eyelids and often coexist with dyslipidemia. They appear clinically as yellowish papules that vary in size. Epidermal cysts are the most common type of skin cyst. They typically occur on the head and neck, and usually affect young adults in their 20s. Milia are common skin lesions that are typically numerous in presence and appear as small-sized sebaceous papules. Seborrheic keratoses are another important type of lesion that are localized on the face and may be disturbing for clients. These are benign tumors that usually appear in individuals over 50 years of age and have an incidence that rises with age. Typically, they are brown in color but they can also be other colors including black, yellow, grey or bluish. Other skin changes include basal cell carcinoma, actinic keratosis, squamous cell carcinoma and lentiginous malignant melanoma. Basal cell carcinoma is a slow-growing, locally malignant epithelial cancer of the skin. This cancer presents mainly in areas exposed to ultraviolet (UV) radiation. Actinic keratosis is a pre-cancerous lesion that is associated with UV radiation. It predisposes to squamous cell carcinoma and other skin cancers rarely. In contrast to basal cell carcinoma, squamous cell carcinoma may cause metastases with high mortality. Melanoma on the head and face usually takes the form of a lentiginous malignant melanoma. This manifests clinically as a brown spot that slowly grows centrifugally. Melanomas vary in size and color. Dermoscopy is an important tool that may help during diagnosis of facial lesions. Given the severe consequences of some skin lesions, it is very important for cosmetologists to have knowledge of the conditions described above. This is because he or she is often the first person who can persuade the client to undergo further diagnosis.

Successful treatment of facial milia in an infant with orofaciodigital syndrome type 1

We report the successful treatment of multiple facial milia with manual extraction and tretinoin in a child with orofaciodigital syndrome type 1. Treatment with topical medications may be insufficient in individuals with orofaciodigital syndrome type 1, and pitted scarring is often a sequala. This case demonstrates that manual extraction is well tolerated and effective in the treatment of multiple milia. In addition, clinicians need to be aware of this rare genetic condition, which commonly presents de novo and can lead to significant morbidity if untreated.

Eruptive milia during isotretinoin therapy

Isotretinoin (13-cis-retinoic acid) is a synthetic vitamin A derivative that is effective in the treatment of recalcitrant, nodulocystic acne. To our knowledge, there are no reports in the medical literature of milia as a side effect of isotretinoin. We report a case of eruptive facial milia in the setting of isotretinoin treatment for acne.

Milia may originate from the outermost layers of the hair bulge of the outer root sheath: A case report

It has been hypothesized that milia originate from the hair bulge of the outer root sheath. To elucidate the histogenesis of milia, an immunohistochemical study was performed using anti-keratin and anti-filaggrin antibodies to determine the levels of keratin and filaggrin expression. Keratin expression was evaluated using anti-keratin antibodies against K1, K7, K8, K10, K14, K15, K16, K17, K18, K19 and K20. K1 and K10 expression were detected in the suprabasal layers of the more superficial section of the cyst walls, but not in the deeper section of the cyst walls. However, K14 and K17 were expressed in all layers of the cyst walls. Notably, K15 was expressed in the outermost layer of the deeper section of the cyst walls and hair germ structure, whereas filaggrin was expressed in the superficial layer of the more superficial section of the cyst walls. Therefore, the pattern of keratin and filaggrin expression indicates that milia may originate from the outermost cells of the hair bulge of the outer root sheath.

Congenital Milium of the Nipple

A 12-month-old girl presented with an asymptomatic, pearly nodule on the left nipple that had been present from birth and was currently 3 mm in diameter and growing. Assuming the diagnosis of congenital primary milium of the nipple, we took a "wait and see" approach. After 3 months, the pearl disappeared without any scarring.

Milia En Plaque as a Distinct Follicular Hamartoma With Cystic Trichoepitheliomatous Features

Milia en plaque (MEP) is an uncommon disorder characterized by an erythematous plaque containing numerous milia. The pathogenesis of MEP is not clear. The authors report a man with an erythematous plaque on the right retroauricular area, containing numerous white-yellow cysts varying in size. Histological examination showed that multiple cystic structures at various levels of the dermis that were lined by stratified squamous epithelium and contained keratinous material-these findings were consistent with the diagnosis of multiple milia. In addition to epidermal cysts, however, the lesion consisted of a branched proliferation of pale-staining keratinocytes lined with basal keratinocytes budding from the overlying epidermis. Moreover, some cysts were formed within the branched epithelial proliferation, had thicker cyst walls than the ordinary milium, or had irregular or branched projections toward the surrounding dermis. From these findings, the authors conclude that MEP is a distinct follicular hamartoma with cystic trichoepitheliomatous features.

Laser treatment of periocular skin conditions

Advances in laser technology in recent decades have increased the options for the treatment of dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal; laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient preparation, safety precautions, and risks--intraocular and extraocular--are discussed herein. As laser technology continues to advance, we are sure to see improvements in current treatments, as well as development of new applications of cutaneous lasers.

Milia en plaque of the nose: report of a case and successful treatment with topical tretinoin

Milia are benign, superficial keratinaceous cysts that present as fine, small white papules. Milia en plaque is a rare, challenging-to-treat variant most often seen in the posterior auricular region. A total of 9 cases of milia en plaque have been reported in the pediatric literature to date. We report a case of milia en plaque of the nose in a 7-year-old boy, a novel site of involvement in the pediatric population, and successful treatment with the use of topical tretinoin. Topical retinoids offer an effective treatment option for the management of milia en plaque in the pediatric population.

Non-choroidal yellow melanoma showing positive staining with Sudan Black consistent with the presence of lipofuscin: a case report

A case of a predominantly yellow primary superficial spreading melanoma arising on the back of a 44-year-old woman is presented. Possible causes of the clinical and dermatoscopic yellow color are discussed. Staining with the histochemical stain, Sudan Black, revealed a differential uptake compared to a closely matched control melanoma. We speculate that the clinical and dermatoscopic yellow color could be due to the presence of increased amounts of the pigment lipofuscin, which is known to produce subtle orange color in some choroidal melanomas.

Perioral lesions and dermatoses

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

Cutaneous effects of BRAF inhibitor therapy: a case series

BACKGROUND

The cutaneous effects of rapidly accelerated fibrosarcoma kinase B (BRAF) inhibitors are not well understood. Squamous cell carcinoma (SCC), keratoacanthoma, and photosensitivity have been described in patients taking BRAF inhibitors.

PATIENTS AND METHODS

To characterize the timing and frequency of skin lesions in patients receiving BRAF inhibitor therapy, we utilized a retrospective case review of 53 patients undergoing treatment with BRAF inhibitors for 4-92 weeks of therapy. Patients were evaluated at baseline, and then followed at 4- to 12-week intervals. Charts were retrospectively reviewed, and the morphology and timing of cutaneous events were recorded.

RESULTS

Thirty-three of the 53 charts met exclusion/inclusion criteria, 15 were treated with vemurafenib, and 18 were treated with GSK 2118436/GSK 1120212. Of 33 patients treated with BRAF inhibitor, 13 developed photosensitivity (39.4%), 10 developed actinic keratoses (30.3%), 10 developed warts (30.3%), and 6 developed SCC (18.2%).

CONCLUSIONS

Multiple cutaneous findings were observed in the 33 patients taking BRAF inhibitors. The previously described association with SCC and photosensitivity was observed in these patients as well. Over half of the observed SCCs were invasive in nature. Photosensitivity continues to be frequent with BRAF inhibitors. Patients taking BRAF inhibitors should have regular full body skin exams. Further studies are necessary to better elucidate the rates of these adverse cutaneous effects.

Profuse congenital familial milia with absent dermatoglyphics (Basan's Syndrome): description of a new family

Milia are common, small, keratin-containing cysts frequently seen in all age groups. They may arise spontaneously or develop after a variety of stimuli. They can be found alone or as part of syndromes. We present a female neonate born not only with profuse facial milia, but also with acral bullae and absent dermatoglyphics. Similar features were seen in several members of her family. These findings correspond to the syndrome known as Basan's syndrome, a rare autosomal-dominant inherited dermatosis characterized by profuse congenital milia, transient neonatal acral bullae, and absence of dermatoglyphics.

Prevalence of milia and palatal and gingival cysts in Spanish newborns

We performed a descriptive survey of 1,000 consecutive newborns cared for in the first 3 days of life in the health area of Ferrol (in northwest Spain) to assess the prevalence and most-frequent locations of oral cysts and milia and to study the influence of different maternal and neonatal parameters in the development of these lesions. Prevalence of palatal, gingival, and cutaneous cysts was 53.7%, 13.4%, and 16.6%, respectively. Milia were predominantly located on the cheeks, chin, and forehead. We found a frequent association between palatal and gingival cysts but not between oral cysts and milia. Neonatal factors such as sex, weight at birth, and gestational age can significantly influence the development of palatal and gingival cysts.

Cloudy and starry milia-like cysts: how well do they distinguish seborrheic keratoses from malignant melanomas?

BACKGROUND

Seborrheic keratoses are the most common skin lesions known to contain small white or yellow structures called milia-like cysts (MLCs). Varied appearances can sometimes make it difficult to differentiate benign lesions from malignant lesions such as melanoma, the deadliest form of skin cancer found in humans.

OBJECTIVE

The purpose of this study was to determine the statistical occurrence of MLCs in benign vs. malignant lesions.

METHODS

A medical student with 10 months experience in examining approximately 1000 dermoscopy images and a dermoscopy-naïve observer analysed contact non-polarized dermoscopy images of 221 malignant melanomas and 175 seborrheic keratoses for presence of MLCs.

RESULTS

The observers found two different types of MLCs present: large ones described as cloudy and smaller ones described as starry. Starry MLCs were found to be prevalent in both seborrheic keratoses and melanomas. Cloudy MLCs, however, were found to have 99.1% specificity for seborrheic keratoses among this group of seborrheic keratoses and melanomas.

CONCLUSION

Cloudy MLCs can be a useful tool for differentiating between seborrheic keratoses and melanomas.

Variants of milia successfully treated with CO(2) laser vaporization

BACKGROUND

Milia are a usual consultation in dermatologic practice and optimal treatment modalities are not established.

OBJECTIVE

To evaluate the efficacy and the safety of CO(2) laser vaporization in the treatment of milia.

METHODS

We report four patients, aged from 12 to 50 years old, with different variants of milia: milia en plaque, milia post-photodermatitis, multiple eruptive milia and milia post-trauma. They were treated with the CO(2) laser in superpulsed and focused mode at 2 W/cm(2), with two passes in each session. The follow-up was 12-36 months.

RESULTS

All patients showed marked improvement after a few sessions of CO(2) laser. No-one had recurrence or noticeable side effects.

CONCLUSION

The CO(2) laser is an option in adult and child patients with multiple milia lesions or milia en plaque, obtaining good cosmetic results with minimal side effects.

Idiopathic multiple eruptive milia occurred in unusual sites

Milia are small, white, benign keratinous cysts that are frequently encountered. Multiple eruptive milia are rare, and are characterized by the development of milia that are more extensive in number and distribution than would be expected in primary milia. We report a case of a 19-year-old girl with tiny, white papules in her axillae and on her abdomen with a review of the relevant literature.