Day: November 9, 2020

What Are the Oral Equivalents of Milia of the Face?

Patient Presentation
A 2-week-old male came to clinic for his health supervision visit. The family had many first-time parent questions and were adapting to the infant and his needs. The past medical history showed a term male born without difficulties.

The pertinent physical exam he was 3.645 kg, and was past birth weight of 3.380 kg. His length and head circumference were 75%. On physical examination he showed a few lesions of erythema toxicum on his cheeks. On his alveolar ridge he had some fluid-filled inclusions on the palate mid-line and posterior. The rest of his examination was normal.

The diagnosis of a healthy male with erythema toxicum and Epstein’s pearls was made. The family had not noticed the Epstein’s pearls and became concerned. The physician noted how these were a normal variation and would resolve as would the erythema toxicum.

Discussion
Milia are small, usually < or = to 3 mm, benign, white, superficial keratinous cysts. They can arise spontaneously (are defined as primary) or because of other conditions (are defined as secondary). Milia can occur at any age but are common in adult patients. However, primary care providers for neonates see it commonly as well as congenital milia occurs in 40-50% of newborns.

Milia occurs more often on the face (especially the nose), but also scalp, neck/upper parts of the trunk and upper extremities. They usually resolve spontaneously in a few weeks, but patient and parent preference may dictate treatment. Treatment options include simple extraction by nicking and lateral pressure to extract the keratin. Other options include topical retinoids, electrocautery, or electrodissection. The differential diagnosis for congenital milia usually includes molluscum contagiosum which has a central umbilication, miliaria crystallinia which has pin-point clear vesicles, sebaceous hyperplasia which is usually more yellow than white in color, transient neonatal pustular melanosis where the vesicles present at birth rupture in a couple of days and heal with hyperpigmentation or candidal or bacterial lesions.

Various images of milia can be seen in “To Learn More” below.

Benign primary milia in children and adults occur spontaneously but are more likely to involve the eyelids and cheeks.

Other milia variations include:

  • Milia en plaque which is rare but has an erythematous plaque lesion with multiple milia lesions contained within it.
  • Nodular grouped milia are also uncommon and are similar but have a nodule with multiple milia contained within it.
  • Generalized milia with nevus depigmentosus where multiple milia are found in the area of hypopigmentation.
  • There are multiple genetic syndromes which also include milia as part of their syndrome. For example hereditary vitamin D dependent rickets, or basal cell nervus syndrome.
  • Secondary milia are localized milia but associated with disease, trauma or medications. They can resolve spontaneously but are less likely.

Learning Point
Oral equivalents of congenital milia are seen with the oral inclusion cysts called Epstein’s pearls on the palate near the midline raphe or Bohn’s nodules on the alveolar ridge and lateral palate.

Questions for Further Discussion

1. What are some options for oral thrush treatment? A review can be found here
2. What causes leukoplakia? A review can be found here
3. What are some of the skills dentists bring to overall pediatric health?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Common Infant and Newborn Problems.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol. 2008;59(6):1050-1063. doi:10.1016/j.jaad.2008.07.034

Kansal NK, Agarwal S. Neonatal milia. Indian Pediatr. 2015;52(8):723-724.

Wang AR, Bercovitch L. Congenital Milia En Plaque. Pediatr Dermatol. 2016;33(4):e258-259. doi:10.1111/pde.12888

Zaouak A, Chamli A, Ben Jennet S, Hammami H, Fenniche S. Milia en plaque. La Presse Medicale. 2019;48(12):1589-1590. doi:10.1016/j.lpm.2019.09.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa