Miliaria 

Updated: May 24, 2018
Author: Nikki A Levin, MD, PhD; Chief Editor: Dirk M Elston, MD 

Overview

Background

Miliaria is a common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity. Miliaria is thought to be caused by blockage of the sweat ducts, which results in the leakage of eccrine sweat into the epidermis or dermis.[1, 2] Note the image below.

Miliaria crystallina in an infant. Note that the l Miliaria crystallina in an infant. Note that the lesions are confluent. Courtesy of K.E. Greer, MD.

See 13 Common-to-Rare Infant Skin Conditions, a Critical Images slideshow, to help identify rashes, birthmarks, and other skin conditions encountered in infants.

The 3 types of miliaria are classified according to the level at which obstruction of the sweat duct occurs. In miliaria crystallina, ductal obstruction is most superficial, occurring in the stratum corneum. Clinically, this form of the disease produces tiny, fragile, clear vesicles. In miliaria rubra, obstruction occurs deeper within the epidermis and results in extremely pruritic erythematous papules. In miliaria profunda, ductal obstruction occurs at the dermal-epidermal junction. Sweat leaks into the papillary dermis and produces subtle asymptomatic flesh-colored papules. When pustules develop in lesions of miliaria rubra, the term miliaria pustulosa is used. Note the images below.

Miliaria pustulosa. Courtesy of K.E. Greer, MD. Miliaria pustulosa. Courtesy of K.E. Greer, MD.
Miliaria pustulosa. Courtesy of K.E. Greer, MD. Miliaria pustulosa. Courtesy of K.E. Greer, MD.

Miliaria rubra can cause great discomfort, and miliaria profunda may lead to heat exhaustion. Treatment of these conditions is warranted. See Heat Illness: How To Cool Off Hyperthermic Patients, a Critical Images slideshow, for tips on treatment options for these patients.

Pathophysiology

The primary stimuli for the development of miliaria are conditions of high heat and humidity that lead to excessive sweating. Occlusion of the skin due to clothing, bandages, transdermal medication patches,[3] or plastic sheets (in an experimental setting) can further contribute to pooling of sweat on the skin surface and overhydration of the stratum corneum. In susceptible persons, including infants, who have relatively immature eccrine glands, overhydration of the stratum corneum is thought to be sufficient to cause transient blockage of the acrosyringium. Foxc1 knockout in mice produces miliaria, suggesting a genetic predisposition may exist.[4]

If hot humid conditions persist, the individual continues to produce excessive sweat, but he or she is unable to secrete the sweat onto the skin surface because of ductal blockage. This blockage results in the leakage of sweat en route to the skin surface, either in the dermis or epidermis, with relative anhidrosis.

When the point of leakage is in the stratum corneum or just below it, as in miliaria crystallina, little accompanying inflammation is present, and the lesions are asymptomatic. In contrast, in miliaria rubra, the leakage of sweat into the subcorneal layers produces spongiotic vesicles and a chronic periductal inflammatory cell infiltrate in the papillary dermis and lower epidermis. In miliaria profunda, the escape of sweat into the papillary dermis generates a substantial, periductal lymphocytic infiltrate and spongiosis of the intra-epidermal duct.

Resident skin bacteria, such as Staphylococcus epidermidis and Staphylococcus aureus, are thought to play a role in the pathogenesis of miliaria, possibly through formation of biofilms.[5, 6]  Patients with miliaria have three times as many bacteria per unit area of skin as healthy control subjects. Antimicrobial agents are effective in suppressing experimentally induced miliaria. Periodic acid-Schiff-positive diastase-resistant material has been found in the intraductal plug that is consistent with staphylococcal extracellular polysaccharide substance (EPS). In an experimental setting, only the strains of S epidermidis that produce EPS can induce miliaria.[7]

In late-stage miliaria, hyperkeratosis and parakeratosis of the acrosyringium are observed. A hyperkeratotic plug may appear to obstruct the eccrine duct, but this is now believed to be a late change and not the precipitating cause of the sweat blockage.

Etiology

The following causes are recognized:

  • Immaturity of the eccrine ducts: Neonates are thought to have immature eccrine ducts that easily rupture when sweating is induced; this rupture leads to miliaria.

  • Occlusion of the skin, as with transdermal drug patches[3]

  • Occlusive clothing: Eighteen cases of miliaria rubra have been reported in US Army personnel who routinely wore flame-resistant army combat uniforms composed of a 65% rayon/25% Kevlar/10% nylon blend while serving in the hot, arid conditions of Afghanistan.[8]

  • Lack of acclimatization: Miliaria is common in individuals who move from a temperate climate to a tropical climate. The condition usually resolves after the individual has lived in the hot, humid conditions for many months.

  • Hot, humid conditions: Tropical climates, incubators in neonatal nurseries, and febrile illnesses may precipitate miliaria.

  • Exertion or high fever: Any stimulus to sweat may precipitate or exacerbate miliaria.

  • Type I pseudohypoaldosteronism: This disorder of mineralocorticoid resistance leads to excessive loss of salt through eccrine secretions and is associated with repeated episodes of pustular miliaria rubra.[9, 10, 11]

  • Morvan syndrome: Miliaria rubra has been reported in this rare autoimmune disorder characterized by neuromyotonia, insomnia, hallucinations, pain, weight loss, and hyperhidrosis.[12]

  • Drugs: Bethanechol, a drug that promotes sweating, has been reported to cause miliaria, as have clonidine and neostigmine.[13] Isotretinoin, a drug that affects follicular differentiation, also has been reported to cause miliaria.[14] Miliaria crystallina has been reported following administration of doxorubicin or erythropoietin.[15, 16]

  • Bacteria: Staphylococci are associated with miliaria, and antibiotics prevent miliaria in an experimental setting.

  • Ultraviolet radiation: Some researchers found that miliaria crystallina preferentially occurs in UV-exposed skin.[17]

Epidemiology

Frequency

United States

Miliaria crystallina is a common condition that occurs in neonates, with a peak in those aged 1 week, and in individuals who are febrile or those who recently moved to a hot, humid climate. Miliaria rubra also is common in infants and adults who move to a tropical environment; this form occurs in as many as 30% of persons exposed to such conditions. Miliaria profunda is a rarer condition that occurs in only a minority of those who have repeated bouts of miliaria rubra.

International

The best data about the incidence of miliaria in newborns are from a Japanese survey of more than 5000 infants.[18] This survey revealed that miliaria crystallina was present in 4.5% of the neonates, with a mean age of 1 week. Miliaria rubra was present in 4% of the neonates, with a mean age of 11-14 days. A 2006 survey study from Iran found an incidence of miliaria of 1.3% in newborns.[19] A survey of pediatric patients in Northeastern India showed an incidence of miliaria of 1.6%.[20]

Worldwide, miliaria is most common in tropical environments, especially among people who recently moved to such environments from more temperate zones. Miliaria has been a significant problem for American and European military personnel who serve in Southeast Asia and the Pacific.

Race

Miliaria occurs in individuals of all races, although some studies show that Asians, who produce less sweat than whites, are less likely to have miliaria rubra.

Sex

No sex predilection is recognized.

Age

Miliaria crystallina and miliaria rubra can occur in persons of any age, but the diseases are most common in infants. In a Japanese survey of more than 5,000 infants, miliaria crystallina was present in 4.5% of the neonates, with a mean age of 1 week. Miliaria rubra was present in 4% of the neonates, with a mean age of 11-14 days.

Three cases of congenital miliaria crystallina are reported.[21, 22, 23]

Miliaria profunda is more common in adults than in infants and children.

Prognosis

Most patients recover uneventfully within a matter of weeks, once they move to a cooler environment.

The complications of miliaria are altered heat regulation and secondary infection (see Complications).

Miliaria crystallina is generally an asymptomatic self-limited condition that resolves without complications over a period of days. It may recur if hot, humid conditions persist.

Miliaria rubra also tends to resolve spontaneously when patients are moved to a cooler environment. Unlike patients with miliaria crystallina, however, those with miliaria rubra tend to be symptomatic; they may report itching and stinging. Anhidrosis develops in the affected sites and may last weeks. If generalized, anhidrosis can lead to hyperpyrexia and heat exhaustion. Secondary infection is another possible complication of miliaria rubra; this appears as either impetigo or multiple discrete abscesses known as periporitis staphylogenes.

Miliaria profunda is itself a complication of repeated episodes of miliaria rubra. The lesions of miliaria profunda are asymptomatic, but compensatory facial and axillary hyperhidrosis may develop.[24] The widespread inability to sweat, the result of eccrine ductal rupture, is known as tropical anhidrotic asthenia; this condition predisposes patients to heat exhaustion during exertion in warm climates.

Some authors believe that subclinical miliaria is an initiating step in development of atopic dermatitis. Their evidence is histopathology showing PAS-positive material and bacteria present in the acrosyringium in cases of atopic dermatitis, whereas no blockage of eccrine ducts was seen in controls.[25]

Patient Education

Patients who have had miliaria, especially miliaria profunda, must be aware of the role of heat and humidity in precipitating this condition.

These patients should be advised to wear lightweight clothing, stay out of the sun, avoid exertion in hot weather, and stay in an air-conditioned environment as much as possible.

 

Presentation

History

Miliaria crystallina

This form usually affects neonates younger than 2 weeks and adults who are febrile or those who recently moved to a tropical climate.

Lesions appear in crops within days to weeks of exposure to hot weather and disappear within hours to days.

Lesions are generally asymptomatic.

Miliaria rubra

This form usually affects neonates aged 1-3 weeks and adults who live in hot, humid environments.

Lesions may occur under transdermal medication patches.[3]

Lesions may occur within days of exposure to hot conditions, but they tend to appear after months of exposure.

Lesions resolve within days after the patient is removed from the hot, humid environment.

Lesions cause intense pruritus and stinging that is exacerbated by fever, heat, or exertion.

Patients may report fatigue and heat intolerance, and they may notice decreased or absent sweating at the affected sites.

Miliaria profunda

This form occurs in individuals who usually live in a tropical climate and have had repeated episodes of miliaria rubra.

Lesions develop within minutes or hours after the stimulation of sweating. These lesions resolve quickly, usually in less than an hour after the stimulus that causes sweating is removed.

The lesions are asymptomatic.

Patients may report increased sweating in unaffected skin; swollen lymph nodes; hyperpyrexia; and symptoms of heat exhaustion, which include dizziness, nausea, dyspnea, and palpitations.

A rare giant centrifugal variant of miliaria profunda has been reported in 2 infants, each at about age 3 months, who presented with symmetrical asymptomatic lesions on the trunk and extensor extremities after a low-grade fever. Unlike most forms of miliaria, the lesions in these children persisted for months.[26]

Physical Examination

Miliaria crystallina

Lesions are clear, superficial vesicles that are 1-2 mm in diameter.

Lesions occur in crops and are often confluent, without any surrounding erythema.

In infants, lesions tend to occur on the head, neck, and upper part of the trunk.

In adults, lesions occur on the trunk.

Lesions rupture easily and resolve with superficial branny desquamation.

See the images below.

Miliaria crystallina in an infant. Note that the l Miliaria crystallina in an infant. Note that the lesions are confluent. Courtesy of K.E. Greer, MD.
Miliaria crystallina in a newborn child. Courtesy Miliaria crystallina in a newborn child. Courtesy of K.E. Greer, MD.
Miliaria crystallina. Note the water-drop appearan Miliaria crystallina. Note the water-drop appearance of the lesions. Courtesy of K.E. Greer, MD.

Miliaria rubra

Lesions are uniform, small, erythematous papules and vesicular papules on a background of erythema.

Lesions occur in a nonfollicular distribution and do not become confluent.

In infants, lesions occur on the neck and in the groin and axillae.

In adults, lesions occur on covered skin where friction occurs; these areas include the neck, scalp, upper part of the trunk, and flexures. The face and volar areas are spared.

Lesions may occur in erythematous patches similar to sunburn.[27]

In late stages, anhidrosis is observed in affected skin.

See the image below.

Miliaria rubra in an adult. Courtesy of K.E. Greer Miliaria rubra in an adult. Courtesy of K.E. Greer, MD.

Miliaria profunda

Lesions are firm, flesh-colored, nonfollicular papules that are 1-3 mm in diameter.

Lesions occur primarily on the trunk, but they can also appear on the extremities.

Lesions are transiently present after exertion or other stimulus that results in sweating.

Affected skin shows diminished or absent sweating.

In severe cases that lead to heat exhaustion, hyperpyrexia and tachycardia may be observed.

A rare giant centrifugal variant of miliaria profunda has been reported in young infants (of about age 3 mo) who presented with multiple erythematous lichenoid papules that coalesced to form infiltrated annulare and geographic plaques 1-5 cm in size with an erythematous border, located over the trunk and extensor extremities.[26]

Complications

The most common complications of miliaria are secondary infection and heat intolerance.

Secondary infection may appear as impetigo or as multiple discrete abscesses known as periporitis staphylogenes.

Heat intolerance is most likely to develop in patients with miliaria profunda; it is recognized by anhidrosis of the affected skin, weakness, fatigue, dizziness, and even collapse. In its most severe form, this heat intolerance is known as tropical anhidrotic asthenia.

 

DDx

Diagnostic Considerations

Miliaria crystallina and miliaria rubra are common in infants; therefore, pediatricians must be able to distinguish these conditions from other common eruptions that affect infants.

Miliaria crystallina can be confused with congenital herpes simplex, varicella, syphilis, candidiasis, or staphylococcal scalded skin syndrome. Cytologic findings in the blister fluid should rule out these conditions; cytologic methods may involve Tzanck preparation, Gram staining, and potassium hydroxide preparation, as well as the acquisition of a biopsy sample for histopathologic analysis.

Miliaria rubra can be confused with erythema toxicum neonatorum, infantile acne, or folliculitis. Pustules of erythema toxicum are characteristically filled with eosinophils, unlike those of miliaria rubra. Infantile acne typically involves the face in a follicular distribution. Miliaria may involve the face, as well as the trunk and axillae. Superficial folliculitis, as its name suggests, is follicular, unlike miliaria.

Differential Diagnoses

 

Workup

Laboratory Studies

Miliaria is clinically distinctive; therefore, few laboratory tests are necessary.

When miliaria rubra occurs in people with darker skin types, dermoscopy showing large white globules with surrounding darker halos, appearing like a “white bull's eye,” may be helpful in making the diagnosis.[28]

In miliaria crystallina, cytologic examination of the vesicular contents fails to reveal inflammatory cells or multinucleated giant cells (as would be expected in herpes vesicles).

In miliaria pustulosa, cytologic examination of the pustular contents reveals inflammatory cells. Unlike erythema toxicum neonatorum, eosinophils are not prominent. Gram staining may reveal gram-positive cocci (eg, staphylococci).

Imaging Studies

High-definition optical coherence tomography has been used to help establish the diagnosis of miliaria.[29]

Histologic Findings

In miliaria crystallina, intracorneal or subcorneal vesicles communicate with eccrine sweat ducts, without surrounding inflammatory cells. Obstruction of the eccrine duct may be observed in the stratum corneum.

In miliaria rubra, spongiosis and spongiotic vesicles are observed in the stratum malpighian, in association with eccrine sweat ducts. Periductal inflammation is present.

In early lesions in miliaria profunda, a predominantly lymphocytic periductal infiltrate is present in the papillary dermis and lower epidermis. A PAS-positive diastase-resistant eosinophilic cast may be seen in the ductal lumen. In later lesions, inflammatory cells may be present lower in the dermis, and lymphocytes may enter the eccrine duct. Spongiosis of the surrounding epidermis and parakeratotic hyperkeratosis of the acrosyringium may be observed.

In the granulomatous giant centrifugal variant of miliaria profunda, biopsies show mild spongiosis and acanthosis, hypergranulosis, and hyperplasia of the acrosyringia, the eccrine ducts, and infundibula, with invagination by keratin plugs. There is a granulomatous inflammatory infiltrate within the dermis, consisting of lymphocytes and foreign body giant cells with a few neutrophils centered around the ruptured straight portion of the eccrine duct.[26]

 

Treatment

Medical Care

No compelling reason to treat miliaria crystallina exists because this condition is asymptomatic and self-limited.

Miliaria rubra can cause great discomfort, and miliaria profunda may lead to heat exhaustion. Treatment of these conditions is warranted.

The prevention and treatment of miliaria primarily consists of controlling heat and humidity so that sweating is not stimulated. Measures may involve treating a febrile illness; removing occlusive clothing; limiting activity; providing air conditioning; or, as a last resort, having the patient move to a cooler climate.

Topical treatments that have been advocated involve lotions containing calamine, boric acid, or menthol; cool wet-to-dry compresses; frequent showering with soap (although some discourage excessive use of soap); topical corticosteroids; and topical antibiotics.

The topical application of anhydrous lanolin and isotretinoin has resulted in dramatic improvement in patients with miliaria profunda.[24]

The prophylaxis of miliaria with oral antibiotics is reported. Patients have also been treated with oral retinoids, vitamin A, and vitamin C, with variable success. To our knowledge, no controlled trials have been conducted to demonstrate the effectiveness of any of these systemic therapies.

Antimicrobial agents are effective in suppressing experimentally induced miliaria.

Activity

Because increased exertion leads to sweating, which greatly exacerbates miliaria, patients should be advised to limit their activity, especially in hot weather, until the miliaria resolves.

Patients with miliaria profunda are at particularly high risk for heat exhaustion during exertion in hot weather, because their ability to dissipate heat by means of evaporation of sweat is impaired.

Prevention

Patients should avoid exposure to conditions of high heat and humidity.

When patients are in tropical climates, they should wear lightweight clothing, avoid exertion, use sunscreen, and stay in air-conditioned buildings as much as possible.

In patients with a history of miliaria, the application of topical anhydrous lanolin before exercise may help prevent the formation of new lesions.

 

Medication

Medication Summary

The goal of treating miliaria rubra and miliaria profunda is to provide symptomatic relief and prevent hyperpyrexia and heat exhaustion. The authors know of no strong evidence indicating efficacy with systemic medications; therefore, topical medications are preferred.  However, case reports of successful treatment of miliaria profunda with oral isotretinoin exist.[29]

Topical Therapies

Class Summary

Anhydrous lanolin is believed to prevent ductal blockage, allowing sweat to flow to the skin surface. Calamine lotion provides cooling symptomatic relief after miliaria develops.

Lanolin

Lanolin is thought to prevent ductal blockage, allowing sweat to flow to the skin surface.

Calamine lotion (Caladryl)

Calamine lotion provides cooling symptomatic relief after miliaria develops.

 

Questions & Answers