1

DIAGNOSIS & TREATMENT

OF MILIARIA
Group 2
Wan Nuralieya Erissha (C014202028)
Nurin Afrina Binti Mohamad Nasir (C014202030)
Selyn Dion Matasik (C014202046)

Resident Supervisor
dr. Ritami Masita
Consultant Supervisor
Dr. dr. Anni Adriani, Sp.KK (K) , FINSDV, FAADV
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INTRODUCTION
 The major sweat glands in humans are
eccrine and apocrine glands

 Entire body skin, highest density on palms

and soles

 Secretion of sweat provides a mechanism for

thermoregulation via evaporative heat loss,
maintenance of electrolyte balance, and
keeping the stratum corneum moist.

Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 3rd ed. © 2012, Elsevier Limited; 2012. 539-541 p.
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01 Miliaria is a common disorder of the eccrine sweat ducts and occurs in

conditions of increased heat and humidity.

02 Miliaria is an inflammatory skin in humans, which is characterized by

multiple small lesions in the skin’s pores due to blockage of sweat ducts.

Based on the World Health Organization (WHO) in 2016, every year there
03 are 80% of population whom experience prickly heat (miliaria), 65% of
which occur in infants and young children.

04 Miliaria can occur in men and women, all races and all ages.

• Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
• Nagpal, Manju;dkk.Research Journal of Pharmaceutical, Biological and Chemical Sciences.Miliaria: An Update.2017
• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta.
• Setyowati, M., & Kusumastuti. (2019). Penerapan Virgin Coconut Oil ( VCO ) untuk Mengobati Biang Keringat ( Miliaria ) pada Bayi di PMB Diana Yulita. 521–528.
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02
DEFINITION
Miliaria results from obstruction of eccrine sweat ducts and occurs in
conditions of increased heat and humidity.

Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
5
The prevalence of miliaria in neonates is 3-8%
EPIDEMIOLOGY

Miliaria also commonly occurs in adults who live or

work in very hot and humid environments.

There is no specific prevalence of race or gender

in the case of miliaria.

Based on the research in Indonesia ,there are 282

cases (22.79%) of the 8919 cases of children under 5
suffering from prickly heat skin disease.

• Setyowati, M., & Kusumastuti. (2019). Penerapan Virgin Coconut Oil ( VCO ) untuk Mengobati Biang Keringat ( Miliaria ) pada Bayi di PMB Diana Yulita. 521–528.
• WILEY Blackwell. Rook’s Textbook of Dermatology. 1st ed. United Kingdom: © 2016 by John Wiley & Sons, Ltd; 2016. 94.12-94.13.  
• Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 4th ed. Jeffrey P. Callen, editor. 2018. 571, 644 p.
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CLASSIFICATION
1 Miliaria Crystallina
Ductal obstruction occurs at
the stratum corneum

Miliaria Rubra
2 Ductal obstruction occurs deeper
within the epidermis

Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.\
Pertiwi AAPS. Miliaria. Jakarta; 2018.
7

3 Miliaria Profunda
Ductal obstruction occurs at the
dermal-epidermal junction

Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.\
Pertiwi AAPS. Miliaria. Jakarta; 2018.
 8 ETIOPATHOGENESIS
-Excessive sweating
Eccrine Blockage
-Elevated concentrations of
duct of sweat
sodium chloride
disruption gland
-High humidity
ducts
-Ultraviolet radiation
-Staphylococcus epidermidis

Swelling &
Ductal blockage cause leakage Retention further
of sweat into the epidermis or of sweat occlusion
dermis into the (lead to duct
skin rupture)

Pertiwi AAPS. Miliaria. Jakarta; 2018.

Nagpal M, Panda P, Aggarwal G. MILIARIA- AN UPDATE Research Journal of Pharmaceutical , Biological and Chemical Sciences Miliaria : An Update . J Pharm Biol Chem Sci. 2017;8(4):1161–8.

WILEY Blackwell. Rook’s Textbook of Dermatology. 1st ed. United Kingdom: © 2016 by John Wiley & Sons, Ltd; 2016. 94.12-94.13.
9
CLINICAL FEATURES
TYPES OF MILIARIA

Most common
Location of obstruction Cutaneous lesions
locations

Non-pruritic, clear,
Crystallina Stratum corneum fragile, Face and trunk
1 mm vesicles

Pruritic, erythematous,
Rubra
Mid-epidermis 1–3 mm papules; Neck and upper trunk
(Prickly Heat)
may have pustules

Dermal–epidermal Non-pruritic, white, 1– Trunk and proximal

Profunda
junction 3 mm papules extremities

Miliaria pustulosa is when pustules develop in lesions of miliaria rubra or preceded by another dermatitis
that has produced injury, destruction, or blocking of the sweat duct.
• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta.
• Paller, Amy S. ;Mancini AJ. Hurwitz Clinical Pediatric Dermatology. 5th ed. Canada: © 2016, Elsevier Inc.; 2016. 15–16 p.
• Guerra, Karla C; Tonca, Alicia;Krishnamurthy K. Miliaria. StatPearls, editor. NCBI Bookshelf. © 2021, StatPearls Publishing LLC; 2021. 1–6 p
• Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 3rd ed. © 2012, Elsevier Limited; 2012. 595–597 p
10

DIAGNOSIS

• Miliaria is a clinical diagnosis.

• A simple diagnostic test consists of the puncture of a miliaria vesicle with a
fine needle, resulting in release of the trapped clear sweat.
• Laboratory tests are often inconclusive and not helpful.
• When in doubt, a skin punch biopsy can be useful to help with diagnosis.

Indonesia PBID. Panduan Praktik Klinis Primer Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2017. 292 p.
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DIAGNOSIS
 
History taking:
• Asymptomatic but patients may experience pruritic and painful symptoms
if inflammatory response is involved.
• History of exposure to hot condition
• Live in tropical climate

Indonesia PBID. Panduan Praktik Klinis Primer Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2017. 292 p.
12

DIAGNOSIS
Physical examination:
Inspection:

1. Miliaria crystalline
a) Consists of (1-2mm) miliar vesicles, subcorneal without
signs of inflammation, easily ruptured by scratching and
desquamation within a few days)
b) Predilection : trunk, face

2. Miliaria rubra
The most common type consists of miliar vesicles or
papulovesicles on an erythematous base around the sweat
ducts, scattered discretely

Indonesia PBID. Panduan Praktik Klinis Primer Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2017. 292 p .
ELSEVIER S. Andrews’ Diseases of the skin : Clinical Dermatology. 11th ed. USA: © 2011, Elsevier Inc. All; 2011. 19–20 p
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DIAGNOSIS
Physical examination:
Inspection:

3. Miliaria pustulose
The pustules are distinct, superficial, and independent
of the hair follicle.
b) The pruritic pustules occur most frequently on the
intertriginous areas, flexure surfaces of the extremities,
scrotum, and back of bedridden patients.

4. Miliaria profunda
a) Whitish Papules (1-3 mm), similar to folliculitis may be
accompanied by pustules
b) Predilection on trunk and proximal extremities

Indonesia PBID. Panduan Praktik Klinis Primer Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2017. 292 p .
Pertiwi AAPS. Miliaria. Jakarta; 2018.
American Academy of Pediatrics. Pediatric Dermatology: A Quick Reference Guide. Krowchuk, Daniel P.; Mancini AJ, editor. © 2007 American Academy of
Pediatrics; 2007. 449–450 p.
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DIAGNOSIS
ADDITIONAL EXAMINATION
Cytological examination:
• Miliaria crystallina : Absence of inflammatory cells or giant keratinocytes

• Miliaria pustulose : Presence of inflammatory cells and gram-positive cocci.

Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 4th ed. Jeffrey P. Callen, editor. 2018. 571 p.
15

DIAGNOSIS

Histopatology:
• Miliaria crystalline : Intracorneal or subcorneal vesicles that are centered
on the acrosyringium corneal or intracorneal vesicles that are centered on
the acrosyringium with relatively little surrounding inflammation

• Miliaria rubra: Intraepidermal spongiosis and vesicles are seen along with a
chronic inflammatory infiltrate in the dermis

Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 4th ed. Jeffrey P. Callen, editor. 2018. 571 p.
16

DIAGNOSIS
Histopatology
Miliaria profunda :
• Differs from rubra by the further rupture of eccrine ducts and more
significant lymphocytic inflammation.

Guerra, Karla C; Tonca, Alicia;Krishnamurthy K. Miliaria. StatPearls, editor. NCBI Bookshelf. ©️2021, StatPearls Publishing LLC; 2021. 3–4 p
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DIFFERENTIAL DIAGNOSIS
Miliaria crystalline 1. Herpes Simplex Infection

2. Varicella

• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta.
• Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
 18 DIFFERENTIAL DIAGNOSIS
Miliaria rubra In neonates:
1. Erythema toxicum neonatorum

2. Neonatal acne

• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakart Sewon Kang. Fitzpatrick’s
Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
 19 DIFFERENTIAL DIAGNOSIS

Miliaria rubra In adults:

1. Folliculitis

2. Candidiasis

• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta.
• Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
 20

DIFFERENTIAL DIAGNOSIS
Miliaria profunda Papular mucinosis

Jean L. Bolognia, Julie V. Schaffer, Lorenzo Cerroni. Dermatology. 4th ed. Jeffrey P. Callen, editor. 2018.
21

TREATMENT
As miliaria is caused in hot and humid conditions, the primary treatment
and prevention for miliaria is to control heat and humidity

Non Pharmacology:
• Control local environment (remove excess bedding, fans, air conditioning)
• Cool the skin ( damp compresses, cool showers)
• Avoid tight or excessive clothing

• WILEY Blackwell. Rook’s Textbook of Dermatology. 1st ed. United Kingdom: © 2016 by John Wiley & Sons, Ltd; 2016. 94.12-94.13.
• Nagpal, Manju;dkk.Research Journal of Pharmaceutical, Biological and Chemical Sciences.Miliaria: An Update.2017
22

TREATMENT
Pharmacology:
Miliaria crystallina Miliaria rubra Miliaria profunda
Self-limited 1. Antiseptic: Clorhexidine lotion • Anhydrous
(resolves without with salycilic acid 1% lanolin topical +
intervention) 2. Mild to moderate potency isotretinoin oral
corticosteroid: Triamcinolone 40 mg for 2
0,1 % cream for 1-2 weeks months
3. Betametasone 0,1 % twice daily
for 3 days,antihistamine (for
cases with severe itching)

• Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta
• Guerra, Karla C; Tonca, Alicia;Krishnamurthy K. Miliaria. StatPearls, editor. NCBI Bookshelf. © 2021, StatPearls Publishing LLC; 2021. 1–6 p
23

COMPLICATION
• Complications that often occur in miliaria are secondary
infection and heat intolerance
• Secondary infection may present as impetigo.
• Miliaria rubra in young infants can predispose to multiple
staphylococcal abscesses.
• Heat intolerance develops in patients with miliaria profunda
and in a severe form known as tropical anhydrotic asthenia.

Adhi, Djuanda,2017. Ilmu Penyakit Kulit dan Kelamin, Edisi 7 Bagian Ilmu Penyakit Kulit dan Kelamin. Fakultas kedokteran Universitas Indonesia. Jakarta
24

PROGNOSIS
• In neonates, Miliaria crystallina improves spontaneously as
the sweat ducts mature.
• Miliaria rubra improves if the predisposing etiological
factors( high heat/humidity and occlusion) are removed

Quo Ad Vitam : Bonam

Quo Ad Sanationam : Bonam
Quo Ad Functionam : Bonam

WILEY Blackwell. Rook’s Textbook of Dermatology. 1st ed. United Kingdom: © 2016 by John Wiley & Sons, Ltd; 2016. 94.12-94.13.
25

CONCLUSION
• Miliaria is a disorder involving vesicles, papules, and pustules of the
skin due to blockage of sweat ducts and humidity.
• There are three types of clinically distinctive miliaria classified based
on the level of the obstruction : miliaria crystalina, miliaria rubra and
miliaria profunda.
• Specific modalities for the treatment of miliaria are unique
depending on the type.

• Sewon Kang. Fitzpatrick’s Dermatology. 9th ed. Mc Graw Hill Education; 2018. 1731 p.
• Guerra, Karla C; Tonca, Alicia;Krishnamurthy K. Miliaria. StatPearls, editor. NCBI Bookshelf. ©️2021, StatPearls Publishing LLC; 2021. 1–6 p
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