9/5/2016 DermatologicManifestationsofMiliaria:Background,Pathophysiology,Epidemiology

DermatologicManifestationsofMiliaria
Author:NikkiALevin,MD,PhDChiefEditor:DirkMElston,MDmore...

Updated:Feb09,2016

Background
Miliariaisacommondisorderoftheeccrinesweatglandsthatoftenoccursin
conditionsofincreasedheatandhumidity.Miliariaisthoughttobecausedby
blockageofthesweatducts,whichresultsintheleakageofeccrinesweatintothe
epidermisordermis. [1,2]Notetheimagebelow.

Miliariacrystallinainaninfant.Notethatthelesionsareconfluent.CourtesyofK.E.Greer,MD.

See13CommontoRareInfantSkinConditions,aCriticalImagesslideshow,to
helpidentifyrashes,birthmarks,andotherskinconditionsencounteredininfants.

The3typesofmiliariaareclassifiedaccordingtothelevelatwhichobstructionof
thesweatductoccurs.Inmiliariacrystallina,ductalobstructionismostsuperficial,
occurringinthestratumcorneum.Clinically,thisformofthediseaseproducestiny,
fragile,clearvesicles.Inmiliariarubra,obstructionoccursdeeperwithinthe
epidermisandresultsinextremelypruriticerythematouspapules.Inmiliaria
profunda,ductalobstructionoccursatthedermalepidermaljunction.Sweatleaks
intothepapillarydermisandproducessubtleasymptomaticfleshcoloredpapules.
Whenpustulesdevelopinlesionsofmiliariarubra,thetermmiliariapustulosais
used.Notetheimagesbelow.

Miliariapustulosa.CourtesyofK.E.Greer,MD.

Miliariapustulosa.CourtesyofK.E.Greer,MD.

Miliariarubracancausegreatdiscomfort,andmiliariaprofundamayleadtoheat
exhaustion.Treatmentoftheseconditionsiswarranted.SeeHeatIllness:HowTo
http://emedicine.medscape.com/article/1070840overview 1/4
9/5/2016 DermatologicManifestationsofMiliaria:Background,Pathophysiology,Epidemiology
CoolOffHyperthermicPatients,aCriticalImagesslideshow,fortipsontreatment
optionsforthesepatients.

Pathophysiology
Theprimarystimuliforthedevelopmentofmiliariaareconditionsofhighheatand
humiditythatleadtoexcessivesweating.Occlusionoftheskinduetoclothing,
bandages,transdermalmedicationpatches, [3]orplasticsheets(inanexperimental
setting)canfurthercontributetopoolingofsweatontheskinsurfaceand
overhydrationofthestratumcorneum.Insusceptiblepersons,includinginfants,who
haverelativelyimmatureeccrineglands,overhydrationofthestratumcorneumis
thoughttobesufficienttocausetransientblockageoftheacrosyringium.

Ifhothumidconditionspersist,theindividualcontinuestoproduceexcessivesweat,
butheorsheisunabletosecretethesweatontotheskinsurfacebecauseofductal
blockage.Thisblockageresultsintheleakageofsweatenroutetotheskinsurface,
eitherinthedermisorepidermis,withrelativeanhidrosis.

Whenthepointofleakageisinthestratumcorneumorjustbelowit,asinmiliaria
crystallina,littleaccompanyinginflammationispresent,andthelesionsare
asymptomatic.Incontrast,inmiliariarubra,theleakageofsweatintothe
subcorneallayersproducesspongioticvesiclesandachronicperiductal
inflammatorycellinfiltrateinthepapillarydermisandlowerepidermis.Inmiliaria
profunda,theescapeofsweatintothepapillarydermisgeneratesasubstantial,
periductallymphocyticinfiltrateandspongiosisoftheintraepidermalduct.

Residentskinbacteria,suchasStaphylococcusepidermidisandStaphylococcus
aureus,arethoughttoplayaroleinthepathogenesisofmiliaria. [4]Patientswith
miliariahave3timesasmanybacteriaperunitareaofskinashealthycontrol
subjects.Antimicrobialagentsareeffectiveinsuppressingexperimentallyinduced
miliaria.PeriodicacidSchiffpositivediastaseresistantmaterialhasbeenfoundin
theintraductalplugthatisconsistentwithstaphylococcalextracellular
polysaccharidesubstance(EPS).Inanexperimentalsetting,onlythestrainsofS
epidermidisthatproduceEPScaninducemiliaria. [5]

Inlatestagemiliaria,hyperkeratosisandparakeratosisoftheacrosyringiumare
observed.Ahyperkeratoticplugmayappeartoobstructtheeccrineduct,butthisis
nowbelievedtobealatechangeandnottheprecipitatingcauseofthesweat
blockage.

Epidemiology
Frequency

UnitedStates

Miliariacrystallinaisacommonconditionthatoccursinneonates,withapeakin
thoseaged1week,andinindividualswhoarefebrileorthosewhorecentlymoved
toahot,humidclimate.Miliariarubraalsoiscommonininfantsandadultswho
movetoatropicalenvironmentthisformoccursinasmanyas30%ofpersons
exposedtosuchconditions.Miliariaprofundaisararerconditionthatoccursinonly
aminorityofthosewhohaverepeatedboutsofmiliariarubra.

International

ThebestdataabouttheincidenceofmiliariainnewbornsarefromaJapanese
surveyofmorethan5000infants. [6]Thissurveyrevealedthatmiliariacrystallina
waspresentin4.5%oftheneonates,withameanageof1week.Miliariarubrawas
presentin4%oftheneonates,withameanageof1114days.A2006surveystudy
fromIranfoundanincidenceofmiliariaof1.3%innewborns. [7]Asurveyofpediatric
patientsinNortheasternIndiashowedanincidenceofmiliariaof1.6%. [8]

Worldwide,miliariaismostcommonintropicalenvironments,especiallyamong
peoplewhorecentlymovedtosuchenvironmentsfrommoretemperatezones.
MiliariahasbeenasignificantproblemforAmericanandEuropeanmilitary
personnelwhoserveinSoutheastAsiaandthePacific.

Race

Miliariaoccursinindividualsofallraces,althoughsomestudiesshowthatAsians,
whoproducelesssweatthanwhites,arelesslikelytohavemiliariarubra.

Sex

Nosexpredilectionisrecognized.

Age

Miliariacrystallinaandmiliariarubracanoccurinpersonsofanyage,butthe
diseasesaremostcommonininfants.InaJapanesesurveyofmorethan5,000
infants,miliariacrystallinawaspresentin4.5%oftheneonates,withameanageof
1week.Miliariarubrawaspresentin4%oftheneonates,withameanageof1114
days.

Threecasesofcongenitalmiliariacrystallinaarereported. [9,10,11]

Miliariaprofundaismorecommoninadultsthanininfantsandchildren.

ClinicalPresentation

ContributorInformationandDisclosures
Author
NikkiALevin,MD,PhDAssociateProfessorofMedicine,DivisionofDermatology,UniversityofMassachusetts
MedicalSchool

http://emedicine.medscape.com/article/1070840overview 2/4
9/5/2016 DermatologicManifestationsofMiliaria:Background,Pathophysiology,Epidemiology

NikkiALevin,MD,PhDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofDermatology,PhiBetaKappa,SigmaXi

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard
MichaelJWells,MD,FAADAssociateProfessor,DepartmentofDermatology,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicine

MichaelJWells,MD,FAADisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofDermatology,AmericanMedicalAssociation,TexasMedicalAssociation

Disclosure:Nothingtodisclose.

RosalieElenitsas,MDHermanBeermanProfessorofDermatology,UniversityofPennsylvaniaSchoolof
MedicineDirector,PennCutaneousPathologyServices,DepartmentofDermatology,UniversityofPennsylvania
HealthSystem

RosalieElenitsas,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,
AmericanMedicalAssociation,AmericanSocietyofDermatopathology,PennsylvaniaAcademyofDermatology

Disclosure:ReceivedroyaltyfromLippincottWilliamsWilkinsfortextbookeditor.

ChiefEditor
DirkMElston,MDProfessorandChairman,DepartmentofDermatologyandDermatologicSurgery,Medical
UniversityofSouthCarolinaCollegeofMedicine

DirkMElston,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology

Disclosure:Nothingtodisclose.

AdditionalContributors
JanetFairley,MDProfessorandHead,DepartmentofDermatology,UniversityofIowa,RoyJandLucilleA
CarverCollegeofMedicine

JanetFairley,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,American
FederationforMedicalResearch,SocietyforInvestigativeDermatology

Disclosure:Nothingtodisclose.

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