9/5/2016 DermatologicManifestationsofMiliariaClinicalPresentation:History,Physical,Causes

DermatologicManifestationsofMiliariaClinical
Presentation
Author:NikkiALevin,MD,PhDChiefEditor:DirkMElston,MDmore...

Updated:Feb09,2016

History
Miliariacrystallina

Thisformusuallyaffectsneonatesyoungerthan2weeksandadultswhoarefebrile
orthosewhorecentlymovedtoatropicalclimate.

Lesionsappearincropswithindaystoweeksofexposuretohotweatherand
disappearwithinhourstodays.

Lesionsaregenerallyasymptomatic.

Miliariarubra

Thisformusuallyaffectsneonatesaged13weeksandadultswholiveinhot,
humidenvironments.

Lesionsmayoccurundertransdermalmedicationpatches. [3]

Lesionsmayoccurwithindaysofexposuretohotconditions,buttheytendto
appearaftermonthsofexposure.

Lesionsresolvewithindaysafterthepatientisremovedfromthehot,humid
environment.

Lesionscauseintensepruritusandstingingthatisexacerbatedbyfever,heat,or
exertion.

Patientsmayreportfatigueandheatintolerance,andtheymaynoticedecreasedor
absentsweatingattheaffectedsites.

Miliariaprofunda

Thisformoccursinindividualswhousuallyliveinatropicalclimateandhavehad
repeatedepisodesofmiliariarubra.

Lesionsdevelopwithinminutesorhoursafterthestimulationofsweating.These
lesionsresolvequickly,usuallyinlessthananhourafterthestimulusthatcauses
sweatingisremoved.

Thelesionsareasymptomatic.

Patientsmayreportincreasedsweatinginunaffectedskinswollenlymphnodes
hyperpyrexiaandsymptomsofheatexhaustion,whichincludedizziness,nausea,
dyspnea,andpalpitations.

Araregiantcentrifugalvariantofmiliariaprofundahasbeenreportedin2infants,
eachataboutage3months,whopresentedwithsymmetricalasymptomaticlesions
onthetrunkandextensorextremitiesafteralowgradefever.Unlikemostformsof
miliaria,thelesionsinthesechildrenpersistedformonths. [12]

Physical
Miliariacrystallina

Lesionsareclear,superficialvesiclesthatare12mmindiameter.

Lesionsoccurincropsandareoftenconfluent,withoutanysurroundingerythema.

Ininfants,lesionstendtooccuronthehead,neck,andupperpartofthetrunk.

Inadults,lesionsoccuronthetrunk.

Lesionsruptureeasilyandresolvewithsuperficialbrannydesquamation.

Seetheimagesbelow.

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9/5/2016 DermatologicManifestationsofMiliariaClinicalPresentation:History,Physical,Causes

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

Miliariacrystallinainanewbornchild.CourtesyofK.E.Greer,MD.

Miliariacrystallina.Notethewaterdropappearanceofthelesions.CourtesyofK.E.Greer,MD.

Miliariarubra

Lesionsareuniform,small,erythematouspapulesandvesicularpapulesona
backgroundoferythema.

Lesionsoccurinanonfolliculardistributionanddonotbecomeconfluent.

Ininfants,lesionsoccurontheneckandinthegroinandaxillae.

Inadults,lesionsoccuroncoveredskinwherefrictionoccurstheseareasinclude
theneck,scalp,upperpartofthetrunk,andflexures.Thefaceandvolarareasare
spared.

Lesionsmayoccurinerythematouspatchessimilartosunburn. [13]

Inlatestages,anhidrosisisobservedinaffectedskin.

Seetheimagebelow.

Miliariarubrainanadult.CourtesyofK.E.Greer,MD.

Miliariaprofunda

Lesionsarefirm,fleshcolored,nonfollicularpapulesthatare13mmindiameter.

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9/5/2016 DermatologicManifestationsofMiliariaClinicalPresentation:History,Physical,Causes
Lesionsoccurprimarilyonthetrunk,buttheycanalsoappearontheextremities.

Lesionsaretransientlypresentafterexertionorotherstimulusthatresultsin
sweating.

Affectedskinshowsdiminishedorabsentsweating.

Inseverecasesthatleadtoheatexhaustion,hyperpyrexiaandtachycardiamaybe
observed.

Araregiantcentrifugalvariantofmiliariaprofundahasbeenreportedinyoung
infants(ofaboutage3mo)whopresentedwithmultipleerythematouslichenoid
papulesthatcoalescedtoforminfiltratedannulareandgeographicplaques15cm
insizewithanerythematousborder,locatedoverthetrunkandextensor
extremities. [12]

Causes
Thefollowingcausesarerecognized:

Immaturityoftheeccrineducts:Neonatesarethoughttohaveimmature
eccrineductsthateasilyrupturewhensweatingisinducedthisruptureleads
tomiliaria.
Occlusionoftheskin,aswithtransdermaldrugpatches [3]
Occlusiveclothing:Eighteencasesofmiliariarubrahavebeenreportedin
USArmypersonnelwhoroutinelyworeflameresistantarmycombat
uniformscomposedofa65%rayon/25%Kevlar/10%nylonblendwhile
servinginthehot,aridconditionsofAfghanistan. [14]
Lackofacclimatization:Miliariaiscommoninindividualswhomovefroma
temperateclimatetoatropicalclimate.Theconditionusuallyresolvesafter
theindividualhaslivedinthehot,humidconditionsformanymonths.
Hot,humidconditions:Tropicalclimates,incubatorsinneonatalnurseries,
andfebrileillnessesmayprecipitatemiliaria.
Exertionorhighfever:Anystimulustosweatmayprecipitateorexacerbate
miliaria.
TypeIpseudohypoaldosteronism:Thisdisorderofmineralocorticoid
resistanceleadstoexcessivelossofsaltthrougheccrinesecretionsandis
associatedwithrepeatedepisodesofpustularmiliariarubra. [15,16,17]
Morvansyndrome:Miliariarubrahasbeenreportedinthisrareautoimmune
disordercharacterizedbyneuromyotonia,insomnia,hallucinations,pain,
weightloss,andhyperhidrosis. [18]
Drugs:Bethanechol,adrugthatpromotessweating,hasbeenreportedto
causemiliaria,ashaveclonidineandneostigmine. [19]Isotretinoin,adrug
thataffectsfolliculardifferentiation,alsohasbeenreportedtocausemiliaria.
[20]Miliariacrystallinahasbeenreportedfollowingadministrationof

doxorubicinorerythropoietin. [21,22]
Bacteria:Staphylococciareassociatedwithmiliaria,andantibioticsprevent
miliariainanexperimentalsetting.
Ultravioletradiation:Someresearchersfoundthatmiliariacrystallina
preferentiallyoccursinUVexposedskin. [23]

DifferentialDiagnoses

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

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

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9/5/2016 DermatologicManifestationsofMiliariaClinicalPresentation:History,Physical,Causes
FederationforMedicalResearch,SocietyforInvestigativeDermatology

Disclosure:Nothingtodisclose.

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