MILIARIA HAND-OUT

1. DEFINITION
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.

2. EPIDEMIOLOGY
a. 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. b. 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. c. Miliaria profunda is more common in adults than in infants and children.

3. ETIOLOGY
The following causes are recognized: a. 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. b. Occlusion of the skin, as with transdermal drug patches c. 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. d. 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. e. Hot, humid conditions: Tropical climates, incubators in neonatal nurseries, and febrile illnesses may precipitate miliaria. f. Exertion: Any stimulus to sweat may precipitate or exacerbate miliaria. g. 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. h. Morvan syndrome: Miliaria rubra has been reported in this rare autoimmune disorder characterized by neuromyotonia, insomnia, hallucinations, pain, weight loss, and hyperhidrosis
1

vesicles occur in the superficial dermis. has been reported to cause miliaria. the eccrine glands are small. PATHOGENESIS Location of the blockage in the sweat duct determining miliary type. Miliaria crystallina 2 . and larger apocrine glands. Keratin blockage or due to Staphylococcus epidermidis in the sweat duct causes bubbles in the stratum spinosum and may break the skin causing inflammation of the skin. ie inside the epidermis. 4. also has been reported to cause miliaria. The top layer consists of the stratum corneum vesicles. where the blockage little deeper. ie at the dermo-epidermal junction. as have clonidine and neostigmine. soles of the feet. a drug that affects follicular differentiation. 6. Eruption of miliary rubra can be turned into a so-called miliaria pustulosa. but most are found on the palms of the hands.  5. Channel is below the blockage broke and then raised vesicles as small white crystal clear. lies deeper and thicker secret. hair and nails. This manifestation arises due to vasodilatation and stimulation of receptors that cause itching by enzymes out of the cells of the epidermis because of sweat into the epidermis. Ultraviolet radiation: Some researchers found that miliaria crystallina preferentially occurs in UV-exposed skin. and back. ANATOMY & PHYSIOLOGY    Skin is divided into three layers: epidermis. Drugs: Bethanechol. located in the superficial dermis with watery secretions. Skin adnexal glands composed of skin. CLASSIFICATION a. This process occurs in miliaria rubra. b. d. spiral duct and empties directly on the skin surface. and subcutaneous. Eccrine glands. dermis. There are two kinds of sweat glands. If the blockage that occurs lie deeper. k. and antibiotics prevent miliaria in an experimental setting. consisting of sebaceous glands and sudorifera/ sweat glands. eccrine sweat glands found all over the surface of the skin. Usually characterized by erythema and itching.i. Isotretinoin. forehead. A single case of miliaria crystallina following doxorubicin administration has been reported. This process resulted in miliaria profunda are generally rare. j. c. a drug that promotes sweating. Skin glands located in the dermis layer. Skin also has adnexal. namely: a. Excessive Sweat and clothing that does not absorb sweat can cause blockages in the superficial stratum corneum and will produce miliaria crystalline. Bacteria: Staphylococci are associated with miliaria.

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. These lesions resolve quickly. and they may notice decreased or absent sweating at the affected sites. and often occurs in tropical climates. which include dizziness.  Lesions may occur under transdermal medication patches. hyperpyrexia. and symptoms of heat exhaustion. humid environment.  The lesions are asymptomatic.  Lesions cause intense pruritus and stinging that is exacerbated by fever. swollen lymph nodes. lichen simplex chronicus. nausea. heat.  Lesions appear in crops within days to weeks of exposure to hot weather and disappear within hours to days. and intertrigo. Miliaria pustulosa d. Miliaria crystallina 3 . Usually there is a history of ever suffered from contact dermatitis.b. Miliaria rubra  This form usually affects neonates aged 1-3 weeks and adults who live in hot.  Lesions develop within minutes or hours after the stimulation of sweating. 2.  Patients may report fatigue and heat intolerance. 4. dyspnea.  Lesions may occur within days of exposure to hot conditions. and palpitations.  Lesions are generally asymptomatic. Miliaria pustulosa The miliary form occurs in individuals who have suffered repeated attacks miliaria rubra.  Lesions resolve within days after the patient is removed from the hot. 3. usually in less than an hour after the stimulus that causes sweating is removed. DIAGNOSIS a.  Patients may report increased sweating in unaffected skin. but they tend to appear after months of exposure. Physical examination 1. or exertion. History 1. Miliaria profunda  This form occurs in individuals who usually live in a tropical climate and have had repeated episodes of miliaria rubra. Miliaria profunda 7. humid environments. b. Miliaria rubra c.

Miliaria profunda  Lesions are firm. upper part of the trunk. but they can also appear on the extremities. A PAS-positive diastase-resistant eosinophilic cast may be seen in the ductal lumen.  Affected skin shows diminished or absent sweating. a predominantly lymphocytic periductal infiltrate is present in the papillary dermis and lower epidermis. anhidrosis is observed in affected skin. without any surrounding erythema.Lesions are clear.  Lesions rupture easily and resolve with superficial branny desquamation.  In infants.  Lesions occur primarily on the trunk. nonfollicular papules that are 13 mm in diameter. intracorneal or subcorneal vesicles communicate with eccrine sweat ducts. In later lesions. 3. In miliaria rubra. erythematous papules and vesicular papules on a background of erythema. Periductal inflammation is present. In miliaria crystallina. lesions occur on the neck and in the groin and axillae.  In severe cases that lead to heat exhaustion. Obstruction of the eccrine duct may be observed in the stratum corneum.  Lesions are transiently present after exertion or other stimulus that results in sweating. inflammatory cells may be present lower in the dermis. flesh-colored. lesions occur on the trunk. without surrounding inflammatory cells. small.  Lesions occur in a nonfollicular distribution and do not become confluent. The face and volar areas are spared.  Lesions occur in crops and are often confluent. and lymphocytes may enter the  4 . and upper part of the trunk. 3.  In late stages. Miliaria pustulosa  Deep white papules  Looks erythema vesicles containing pus (pustules) 4. lesions occur on covered skin where friction occurs. and flexures. 2.  In infants. in association with eccrine sweat ducts.  In adults. Histologic Findings 1. neck. these areas include the neck. scalp. superficial vesicles that are 1-2 mm in diameter. spongiosis and spongiotic vesicles are observed in the stratum malpighian. lesions tend to occur on the head. Miliaria rubra  Lesions are uniform. hyperpyrexia and tachycardia may be observed. In early lesions in miliaria profunda. 2.  In adults. c.

Classic shape with satellite lesions. 3. slightly damp. Spongiosis of the surrounding epidermis and parakeratotic hyperkeratosis of the acrosyringium may be observed. HSV-2 infection is transmitted through the content (of the mother at birth episode) and sexually transmitted 4. Folliculitis 1. irregular edges. DIFFERENTIAL DIAGNOSIS a.eccrine duct. vesicles. 8. Folliculitis is defined histologically as the presence of inflammatory cells within the wall and ostia of the hair follicle. and papules. began in the crease area. There is enlargement of the 5 . with more than 90% of cases occurring in children younger than 10 years. Herpes simplex viruses (HSVs) are DNA viruses that cause acute skin infections and present as grouped vesicles on an erythematous base. 2. The disease is benign in the healthy child. Chickenpox is largely a childhood disease. Infections of the skin folds. which if broken would happen erosion. HSV-1 infection is transmitted through saliva. pustules. although excoriation or secondary bacterial superinfection predisposes to scar formation. although the primary herpes gingivostomatitis can be observed at any age. b. a typical erythematous. especially in obese people. c. Neonates and adults aged over 65 years are most vulnerable to this candida colonization. 2. Lesions characteristically heal without scarring. Candidiasis 1. creating a follicular-based pustule. Chickenpox is clinically characterized by the presence of active and healing lesions in all stages of development within affected locations. Cutaneous candidiasis and other forms of candidosis are infections caused by the yeast Candida albicans or other Candida species. Clinical symptoms of grouped vesicles and pustules on an erythematous plaque fibers edema. surrounded by an erythematous halo. Can be accompanied by pain and intense itching. The characteristic chickenpox vesicle. and increased morbidity occurs in adults and immunocompromised patients 2. Herpes simplex 1. Varicella 1. Folliculitis can be seen in persons of all ages. d. The varicella-zoster virus (VZV) is the etiologic agent of the clinical syndrome of chickenpox (varicella). is described as a dewdrop on a rose petal 3. 2. and generally found in children. 3.

avoid exertion in hot weather. TREATMENT a. Secondary infection may appear as impetigo or as multiple discrete abscesses known as periporitis staphylogenes. 4.25%. it is recognized by anhidrosis of the affected skin. Ascorbat acid 500 mg. b. calamine lotion can be given with or without menthol 0. Antipruritus or antihistamines (AH1) such as chlorpheniramine or bromfeniramin 4-8 mg every 4-6 hours 4. Heat intolerance is most likely to develop in patients with miliaria profunda. spirits. Faberi lotion with a composition of salicylic acid. 6 . talcum powder. Aromatic retinoids such as isotretinoin 0. zinc oxyd. Topical corticosteroid 5.PROGNOSIS Most patients recover uneventfully within a matter of weeks. Salicylic powder 2% spiked with menthol ¼% -2% 2.5 mg/kg 10. 11. Topical Therapy 1. and even collapse. dizziness. this heat intolerance is known as tropical anhidrotic asthenia. Education 1. fatigue. Lanolin anhidrat 6. and stay in an airconditioned environment as much as possible. stay out of the sun. must be aware of the role of heat and humidity in precipitating this condition. For miliaria profunda. Antibiotic  prophylaxis 2. and menthol 3. The most common complications of miliaria are secondary infection and heat intolerance. weakness. once they move to a cooler environment. c. 2. In its most severe form.COMPLICATIONS a. Benzoil peroksida soap c. amylum oryzae. 2 X 1 3. but fever and constitutional symptoms are usually mild. b. may also resorsin 3% in alcohol.regional lymph nodes. especially miliaria profunda. Systemic Therapy 1. Patients who have had miliaria. These patients should be advised to wear lightweight clothing. 9.

Sign up to vote on this title
UsefulNot useful