Don't try prodding and picking at a milia; they're far more hardened than pimples and can leave scars. Worse, it can result in the area getting inflamed and infected. Image Credit: Shutterstock

As if pimples weren’t bad enough. There’s milia too, a patch of tiny white bumps that form on the face. With the appearance of a hard, white ball, these are actually dead skin cells that get trapped below the skin.

It’s a common affliction for many adults. Dubai-based Asha Menon, a British-Indian public relations professional, finds herself dealing with these spots on her legs for several months in a year. “On some days, it has clouded even my eyelids,” she says, rather frustrated. “Once, I made the mistake of scratching at them and now I have a permanent scar on my legs.”

As she warns with a sigh, don’t even think of picking at milia. They fight back with a vengeance.

So what’s the reason behind milia?

What causes these bumps?

Usually, milia disappears on its own after a few months. However, milia, which develops as a result of sun exposure, blistering or procedures, might need extensive care and treatment. Image Credit: Shutterstock

They form when keratin, a strong protein found in skin tissues, hair and cells, becomes trapped beneath the surface of the skin. As Alaa El Chami, Natural Aesthetics Doctor, Wellth explains, “Normally, the skin sheds dead cells to make way for new ones. However, milia occurs when this process is affected. The dead skin cells get stuck under new layers, forming a milium,” she explains.

Milia essentially comes in two forms:

Primary milia: The most common kind of milia, which appears mostly in newborns and younger adults. The cysts are typically seen on the face, scalp and upper torso. They disappear on their own, after a few months, explains Shreya Kakkar, a Dubai-based dermatologist.

Secondary milia: This could develop at any age, and could be the result of sun exposure, injuries like minor burns or blisters, or even harsh skincare products can damage the outer layer of skin. Such products create difficulties in the shedding process and leading to milia formation.

This kind of milia can develop in an area following a blistering process, or ulcers from either trauma or procedures, adds Kakkar. ‘Traumatic’ milia is when the milia forms where injury to the skin has occurred, which include severe burns and rashes. The cysts may become irritated, making them red along the edges and white in the center.

Milia and healing

Ironically, it could be a sign of healing too, especially in certain rare blistering diseases. For instance, Porphyria Cutanea Tarda (PCT) and Epidermolysis Bullosa (EB) can cause blistering, and when these blisters heal, they may leave milia behind, explains Tamara Alizeh, a senior medical aesthetician based in Dubai.

As she describes, Porphyria cutanea tarda (PCT) is caused by deficiency in an enzyme involved in heme production, a molecule essential for the transport of oxygen in red blood cells. This deficiency leads to a buildup of porphyrins, chemicals that can damage the skin when exposed to sunlight. The main symptom of PCT is blistering on sun-exposed areas like the face, hands, arms, and upper body. The blisters heal with milia and scarring. “When the blisters heal, little remnants of skin get trapped in there,” she says.

Normally, the skin sheds dead cells to make way for new ones. However, milia occurs when this process is affected. The dead skin cells get stuck under new layers, forming a milium...

- Alaa El Chami, Natural Aesthetics doctor, Wellth, Dubai

Epidermolysis bullosa, on the other hand, is group of inherited genetic disorders that cause fragile skin, which blister easily. The trademark is the formation of blisters on the skin like milia, as she says.

Milia can also be linked to genetics; if someone in your family has them, it’s quite possible that you could get it too.

The rare variants of milia

The story of milia doesn’t end there: It has different variants, including multiple eruptive milia (MEM) and milia en plaque.

MEM is exactly as it sounds. The lesions erupt quickly over the face and torso, and is associated with many skin afflictions such as multiple trichoepithelial syndrome. They are far more than the regular and benign milia. The cysts are lined by flattened, tightly packed tissues, called stratified squamous epithelium. The causative factors for this are still relatively unknown, as Alizeh says. It could even be inherited.

On the other hand, milia en plaque, could be a rare symptom of many autoimmune diseases. “It’s a rare type of milia that often affects women between the ages of 40 and 60,” explains Alizeh. “The milia are clustered together on a raised patch of skin, usually behind your ears, on your eyelid, on your cheek or jaw,” she adds. In diseases such as discoid lupus and lichen planus, the milia often forms on thickened, inflamed areas of skin that are referred to as plaques. However, it’s extremely rare and there have been only been a handful of case studies.

Case in point….

There was no history of trauma or even a skin disease.

According to a 2017 case study in the Korean academic and research journal Soonchunhyang Medical Science, a 21-year-old man found himself with multiple, skin-coloured pustules on his abdomen. The lesions had first appeared two years ago, and suddenly spread.. Upon physical examination, it was found that he had multiple firm 1-3mm diameter skin-coloured bumps on his torso, hands, feet and rest. As he was further investigated, it was found that he had two cysts filled with keratin, and it was found consistent with milia. He was diagnosed with MEM, and received antibiotics, triggering remission.

Why you should never pick milia

Picking at a pimple is bad enough, but milia is a different ballgame altogether.

“Milia has a tougher outer layer, as compared to pimples,” says Kakkar. Poking and prodding at them can cause damage to the surrounding skin, leading to permanent scarring. This is especially true for milia on delicate areas like the eyelids, she says. Moreover, she adds that milia are sterile. If you prod them with unwashed hands, it could lead to further inflammation, redness and more milia. “You get trapped in the cycle of more milia,” she says.

Furthermore, milia are actually trapped beneath the skin. If you pick the milium, it spreads the keratin and causes more milia to form in the surrounding area, she says.

How can you treat milia?

Gentle exfoliation can help with reducing milia. Image Credit: Shutterstock
The AHA moment!
Alpha-hydroxy acids (AHAs) and beta-hydroxy acids (BHAs) are chemical exfoliants that help to gently dissolve dead skin cells.

For the most part, milia doesn’t require treatment as it isn’t harmful, say both the dermatologists. “You do need to be patient, even if it gets incredibly frustrating,” says Alizeh. You can try gentle exfoliations at home around thrice a week, which do prevent dead skin cells from forming. “Look for products containing AHAs, alpha hydroxy acids, or BHAs, beta hydroxy acids that can help with this process. Be gentle, though, as harsh scrubbing can irritate the skin and worsen milia,” she says. However she does advise: Before attempting anything, do check with your healthcare provider about what is really good for your skin.