You are on page 1of 8

Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.

com/article/1070840-overview

This site is intended for healthcare professionals

Miliaria
Updated: Mar 23, 2017
Author: Nikki A Levin, MD, PhD; Chief Editor: Dirk M Elston, MD more...

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 lesions are confluent. Courtesy of K.E. Greer, MD.
View Media Gallery

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.

1 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

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


View Media Gallery

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


View Media Gallery

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.

2 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

Resident skin bacteria, such as Staphylococcus epidermidis and Staphylococcus aureus, are
thought to play a role in the pathogenesis of miliaria. [5] Patients with miliaria have 3 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. [6]

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.

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. [7] 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. [8] A survey of pediatric patients in Northeastern India showed an incidence of miliaria
of 1.6%. [9]

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

3 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

the neonates, with a mean age of 11-14 days.

Three cases of congenital miliaria crystallina are reported. [10, 11, 12]

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. [13] 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. [14]

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.

Clinical Presentation

References

1. Champion RH. Disorders of sweat glands. Champion RH, Burton JL, Burns DA,
Breathnach SM, eds. Textbook of Dermatology. 6th ed. Malden, Mass: Blackwell Scientific
Publications; 1998. 1997-9.

2. Wenzel FG, Horn TD. Nonneoplastic disorders of the eccrine glands. J Am Acad

4 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

Dermatol. 1998 Jan. 38(1):1-17; quiz 18-20. [Medline].

3. Ale I, Lachapelle JM, Maibach HI. Skin tolerability associated with transdermal drug
delivery systems: an overview. Adv Ther. 2009 Oct. 26(10):920-35. [Medline].

4. Cui CY, Ishii R, Campbell DP, Michel M, Piao Y, Kume T, et al. Foxc1 Ablated Mice Are
Anhidrotic and Recapitulate Features of Human Miliaria Sweat Retention Disorder. J
Invest Dermatol. 2017 Jan. 137 (1):38-45. [Medline].

5. Holzle E, Kligman AM. The pathogenesis of miliaria rubra. Role of the resident microflora.
Br J Dermatol. 1978 Aug. 99(2):117-37. [Medline].

6. Mowad CM, McGinley KJ, Foglia A, Leyden JJ. The role of extracellular polysaccharide
substance produced by Staphylococcus epidermidis in miliaria. J Am Acad Dermatol. 1995
Nov. 33(5 Pt 1):729-33. [Medline].

7. Hidano A, Purwoko R, Jitsukawa K. Statistical survey of skin changes in Japanese


neonates. Pediatr Dermatol. 1986 Feb. 3(2):140-4. [Medline].

8. Moosavi Z, Hosseini T. One-year survey of cutaneous lesions in 1000 consecutive Iranian


newborns. Pediatr Dermatol. 2006 Jan-Feb. 23(1):61-3. [Medline].

9. Huda M, Saha P. Pattern of dermatosis among pediatric patients attending a medical


college hospital in northeastern region of India. Indian J Dermatol. 2009. 49:189.

10. Arpey CJ, Nagashima-Whalen LS, Chren MM, Zaim MT. Congenital miliaria crystallina:
case report and literature review. Pediatr Dermatol. 1992 Sep. 9(3):283-7. [Medline].

11. Straka BF, Cooper PH, Greer KE. Congenital miliaria crystallina. Cutis. 1991 Feb.
47(2):103-6. [Medline].

12. Haas N, Henz BM, Weigel H. Congenital miliaria crystallina. J Am Acad Dermatol. 2002
Nov. 47(5 Suppl):S270-2. [Medline].

13. Kirk JF, Wilson BB, Chun W, Cooper PH. Miliaria profunda. J Am Acad Dermatol. 1996
Nov. 35(5 Pt 2):854-6. [Medline].

14. Haque MS, Hailu T, Pritchett E, Cusack CA, Allen HB. The oldest new finding in atopic
dermatitis: subclinical miliaria as an origin. JAMA Dermatol. 2013 Apr. 149(4):436-8.
[Medline].

15. Doshi BR, Mahajan S, Kharkar V, Khopkar US. Granulomatous Variant of Giant Centrifugal
Miliaria Profunda. Pediatr Dermatol. 2012 Jan 26. [Medline].

16. Carter R 3rd, Garcia AM, Souhan BE. Patients presenting with miliaria while wearing flame
resistant clothing in high ambient temperatures: a case series. J Med Case Reports. 2011.
5(1):474. [Medline].

17. Argoubi H, Fitchner C, Richard O, Lavocat MP, Cambazard F, Stephan JL. [Pustular
miliaria rubra and systemic type 1b pseudohypoaldosteronism in a newborn]. Ann
Dermatol Venereol. 2007 Mar. 134(3 Pt 1):253-6. [Medline].

18. Urbatsch A, Paller AS. Pustular miliaria rubra: a specific cutaneous finding of type I
pseudohypoaldosteronism. Pediatr Dermatol. 2002 Jul-Aug. 19(4):317-9. [Medline].

5 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

19. Akcakus M, Koklu E, Poyrazoglu H, Kurtoglu S. Newborn with pseudohypoaldosteronism


and miliaria rubra. Int J Dermatol. 2006 Dec. 45(12):1432-4. [Medline].

20. Tabanelli M, Passarini B, Liguori R, Balestri R, Gaspari V, Giacomini F, et al. Erythematous


papules on the parasternal region in a 76-year-old man. Clin Exp Dermatol. 2008 May.
33(3):369-70. [Medline].

21. Haas N, Martens F, Henz BM. Miliaria crystallina in an intensive care setting. Clin Exp
Dermatol. 2004 Jan. 29(1):32-4. [Medline].

22. Gupta AK, Ellis CN, Madison KC, Voorhees JJ. Miliaria crystallina occurring in a patient
treated with isotretinoin. Cutis. 1986 Oct. 38(4):275-6. [Medline].

23. Godkar D, Razaq M, Fernandez G. Rare skin disorder complicating doxorubicin therapy:
miliaria crystallina. Am J Ther. 2005 May-Jun. 12(3):275-6. [Medline].

24. Kumar S, Mahajan BB, Kaur S, Singh A. Erythropoietin induced miliaria crystallina: A
possible new adverse effect of erythropoietin. Int J Case Rep Images. 2014. 5(9):634637.
[Full Text].

25. Shuster S. Duct disruption, a new explanation of miliaria. Acta Derm Venereol. 1997 Jan.
77(1):1-3. [Medline].

26. Al-Hilo, Maytham M, Al-Saedy SJ, Alwan AI. Atypical Presentation of Miliaria in Iraqi
Patients Attending Al-Kindy Teaching Hospital in Baghdad: A Clinical Descriptive Study.
American Journal of Dermatology and Venereology. 2012. 41-6.

27. Mohanan S, Behera B, Chandrashekar L, Kar R, Thappa DM. Bull's-eye pattern in miliaria
rubra. Australas J Dermatol. 2013 Jun 28. [Medline].

28. Tey HL, Tay EY, Cao T. In vivo imaging of miliaria profunda using high-definition optical
coherence tomography: diagnosis, pathogenesis, and treatment. JAMA Dermatol. 2015
Mar. 151 (3):346-8. [Medline].

Media Gallery

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

of 6

Tables

Back to List

6 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

Contributor Information and Disclosures

Author

Nikki A Levin, MD, PhD Associate Professor of Medicine, Division of Dermatology, University
of Massachusetts Medical School

Nikki A Levin, MD, PhD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Dermatology, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Director for Dermatologic Surgery and Pathology, Center for
Dermatology and Facial and Skin Surgery Center, Plano, TX

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega
Alpha, American Academy of Dermatology, American Medical Association, Texas Medical
Association

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania


School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology,
University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of


Dermatology, American Medical Association, American Society of Dermatopathology,
Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic


Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of


Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J
and Lucille A Carver College of Medicine

Janet Fairley, MD is a member of the following medical societies: American Academy of


Dermatology, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Close

7 dari 8 08/11/2017 12:55


Miliaria: Background, Pathophysiology, Epidemiology https://emedicine.medscape.com/article/1070840-overview

What would you like to print?

What would you like to print?

Print this section: Background


Print the entire contents of Overview

8 dari 8 08/11/2017 12:55

You might also like