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LETTER TO EDITOR
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 177-178

Generalized multiple eruptive milia in an infant – An unusual presentation


Department of Skin and VD, MKCG Medical College and Hospital, Berhampur, Odisha, India

Date of Submission14-Jun-2021
Date of Acceptance26-Dec-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Anjaly Girija Sethukumaran
Department of Skin and VD, MKCG Medical College and Hospital, Berhampur, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_90_21

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How to cite this article:
Sethukumaran AG, Patnaik S, Rout AN, Nayak S. Generalized multiple eruptive milia in an infant – An unusual presentation. Indian J Paediatr Dermatol 2022;23:177-8

How to cite this URL:
Sethukumaran AG, Patnaik S, Rout AN, Nayak S. Generalized multiple eruptive milia in an infant – An unusual presentation. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 Jun 29];23:177-8. Available from: https://www.ijpd.in/text.asp?2022/23/2/177/341476



Madam,

Milia are small epithelium-lined keratinous cysts which seem to occur from the plugging of pilosebaceous or eccrine sweat glands. These can be classified into: primary, when occurrence is spontaneous, and secondary, when milia occur following trauma or disease. Neonatal milia, a common variant of primary milia, is seen in 40%–50% of newborns as 1–2 mm, white dome-shaped papules over face. Persistence of such milia in usual sites or widespread distribution is thought to be associated with various genodermatoses. We report an extremely rare case of multiple eruptive milia (MEM), probably idiopathic, in a 3-month-old otherwise healthy baby which was persistent with widespread distribution.

A 3-month-old baby presented with multiple asymptomatic white papules on face, neck, chest, abdomen, and bilateral upper and lower limbs since birth. The baby was otherwise in good health and was born out of normal vaginal delivery. No history of parental consanguinity was observed. The antenatal, perinatal or postnatal history was uneventful. There was no history of trauma or excessive exposure to sunlight or any similar eruptions noted in other family members. On cutaneous examination, there were multiple, white, firm, discrete, asymptomatic, 1–2 mm papules over face, neck, trunk, and extremities [Figure 1] and [Figure 2]. Oral and genital mucosa, palm, and soles were spared. Our provisional diagnosis was MEM. Histopathological examination (HPE) showed a cyst lined by flattened stratified squamous epithelium containing keratin material [Figure 3]a and [Figure 3]b, confirming the diagnosis as MEM. Genomic sequencing to rule out syndromic associations was not done due to nonavailability. Treatment was desired by parents, needle extirpation in multiple sessions was done for larger lesions, and parents were explained about the benign nature and course of disease. The child is kept under follow-up to further exclude sporadic occurrences and to monitor future development of other associated features.
Figure 1: Multiple pearly white dome-shaped papules over face and chest

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Figure 2: Multiple milia over bilateral lower limbs

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Figure 3: (a) Scanner view showing subepidermal cyst lined by flattened stratified squamous epithelium containing keratin material, suggestive of milium (H and E, ×40). (b) Magnified view showing flattened epithelium lining of keratin cyst (H and E, ×400, pink areas are stain deposits)

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Milia are probably the most common benign tumors of the skin. Sebaceous collar of the lower infundibulum of the hair follicle marks the site of eruption of primary milia in contrast to secondary milia which arise from eccrine ducts.[1] As the name suggests, secondary milia occur secondary to either disease, medication, or trauma. At times, unusual distribution and infrequent syndromic associations have been reported with these benign lesions.

MEM is an infrequently encountered skin disorder, marked by the spontaneous eruption of myriads of milia, over a span of weeks to months.[1] Their number and distribution distinguish them from primary milia. A handful of cases have been reported among patients aged 2 months to 71 years, mostly distributed over the face, chest, upper arms, and back.[1] The first case was published by Meischer in 1957. Langley et al.categorized MEM into three categories, seen spontaneously without a known cause or association, or as hereditary with autosomal dominant inheritance, or seen along with various genodermatoses, such as Rombo syndrome, basaloid follicular hamartoma syndrome, orofacial digital syndrome type 1, pachyonychia congenita, Gardner syndrome, hereditary trichodysplasia (Marie Unna hypotrichosis), and dystrophic form of epidermolysis bullosa.[2],[3]

The etiology of MEM remains obscure. There are published reports suggesting various distinctive triggers for MEM. In older individuals, it was associated with diabetes mellitus with diabetic nephropathy, also seen in renal transplant on cyclosporine use.[4] Sunlight was proposed as the possible precipitant due to its distribution on the face and upper trunk.[3] Few studies suggested that friction may be a trigger and rest others failed to establish a cause.[3]

Miliaria crystalina, eruptive vellus hair cysts, verruca plana, eruptive syringoma, and generalized idiopathic calcinosis cutis mimicking MEM could be considered as differential diagnosis of MEM.[3] Diagnosis is mostly clinical and rarely requires HPE. On HPE, it appears as small keratin-filled cysts that are lined with stratified squamous epithelium.[1] Genomic sequencing can be done to unequivocally establish the diagnosis as idiopathic, since many features may develop later in life.

MEM lacks definitive treatment protocols. Neonatal milia usually subside without treatment. However, psychological distress of patients as well as parental concerns should be considered and milia can be removed if desired. Various treatment modalities advised for milia include excision followed by extrusion of keratin core, CO2 laser, curettage, electrocautery, and electrodessication. Beneficial outcome has also been reported with topical tretinoin, ER: YAG laser.[5] Oral azithromycin was tried and showed improvement in one case report.[1]

Due to absence of facility for genomic sequencing in our setup, we could not establish the idiopathic nature of MEM unequivocally . But the lack of any clinical features of associated genodermatoses among family members supports the idiopathic nature of our case. We report this case to bring awareness among dermatologists, neonatologists and paediatricians regarding this unusual entity so that such cases can be kept under regular follow-up for early detection of any syndromic association.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Batra P, Tsou HC, Warycha M, Votava HJ, Stein J. Multiple eruptive milia. Dermatol Online J 2009;15:20.  Back to cited text no. 1
    
2.
Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: Report of a case, review of the literature, and a classification. J Am Acad Dermatol 1997;37:353-6.  Back to cited text no. 2
    
3.
Cho E, Cho SH, Lee JD. Idiopathic multiple eruptive milia occurred in unusual sites. Ann Dermatol 2010;22:465-7.  Back to cited text no. 3
    
4.
Schoendorff C, Lopez Redondo MJ, Roustan Gullon G, Hospital-Gil M, Requena L, Sanchez Yus E, et al. Multiple epidermoid cysts in a renal transplant recipient taking cyclosporine A. Cutis 1992;50:36-8.  Back to cited text no. 4
    
5.
Connelly T. Eruptive milia and rapid response to topical tretinoin. Arch Dermatol 2008;144:816-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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