What's with those annoying little white heads that just never seem to come to the surface and go away? What is that thick, white stuff that comes out when you finally get so frustrated you pick and poke and finally pop the bump? Milia can be the bane of your existence, particularly when they continue to form despite your best efforts at keeping your skin "clean". Unfortunately, cleanliness isn't problem. The skin's ability to naturally exfoliate is.

Milia are deep seeded white bumps that form when skin cells become trapped rather than exfoliate naturally. The trapped cells become walled off into tiny cysts that appear like white beads below the surface of the skin. Milia can occur on the skin or even on mucous membranes such as the inner surface of the cheek or the vermillion border of the lips.

As the surface is worn away, the tiny cyst may resolve on its own. Far too often, though, intervention to remove the cyst may offer more rapid resolution.

Why Me?

Milia form for a variety of reasons. Some you can fix, others aren't so easily dealt with. But you need to scrutinize your skin care routine whenever milia make their appearance. Although some people naturally make milia, and I certainly expect everyone to have an occasional bump at one time or another, milia are often the result of a problem that has affected the skin's surface.

• Heavy Skin Care Products

  No doubt the most common reason milia form is from smothering your skin with heavy skin care products or hair care items. Comedogenic creams and lotions may prevent the sloughing of dead epidermal skin cells. Hidden problem products include make-up removers not labeled oil-free or non-comedogenic, hair spray, hair mousse and gel, heavy sunscreens and some moisturizers. The eyelids are very thin and more likely to experience problems with milia due to cosmetics. Re-evaluate your eye make-up and eyelid make-up remover if you are finding this to be a concern.

  Certain lipsticks, lip balms and products meant to help with chapped lips may be the cause of little white pearly milia developing around the lipstick edge (aka vermillion border) of the lips. Again, if you see these forming, take a good look at the ingredients on the label. B. Kamins Lip Balm SPF 20 is a good option that will not contribute to milia around the lip area. Kinerase Ultimate Volume Lip Conditioner SPF 20 is an AHA-free exfoliating complex that accelerates cell renewal.

• Prolonged History Of Sun Damage

  The formation of milia can also be due to cumulative sun exposure. Aging skin forms a thicker epidermis that may make it far more difficult for skin cells to find their way out of the glands. And thicker skin also makes for more road blocks in the pathway to exfoliation.

• Porphyria Cutanea Tarda

  Milia can also be associated with certain skin diseases, particularly blistering disorders such as Porphyria Cutanea Tarda. Fortunately, there are other symptoms associated with these blistering diseases. Blisters, for one and increased hair on the face and backs of hands and knuckles, for another. PCT is an unusual disorder. If you have milia, don't initially jump to the conclusion you have a blistering condition.

• Genetics

  Sometimes we just inherit certain undesirable skin tendencies.

What's a Girl (Or Guy) Gonna Do?

Exfoliation can go a long way in helping deal with milia prone skin. By keeping the epidermis thin and smooth, you can cut down on their formation. By mentioning exfoliation, I'm not talking about scrubbing off the top layer of your skin! One way is to use a gentle exfoliating scrub such as DERMAdoctor Physical Chemistry facial microdermabrasion + multiacid chemical peel, Dr. Brandt Microdermabrasion Exfoliating Face Cream, MD Formulations Face & Body Scrub, Peter Thomas Roth Botanical Buffing Beads, or Neova Microdermabrasion Scrub.

Home microdermabrasion with DermaNew Facial Rejuvenation System or DERMAdoctor Physical Chemistry facial microdermabrasion + multiacid chemical peel can be highly effective in smoothing out problem skin.

At-home facial peels and pads such as Dr. Dennis Gross Skincare Alpha Beta Daily Face Peel - 30 applications, MD Formulations My Personal Peel System, Peter Thomas Roth Gentle Complexion Correction Pads or help exfoliate surface skin cells, addressing skin texture. How clean is your skin? The Clarisonic CLASSIC Skincare Brush - White Sonic Cleanser System uses proprietary sonic technology and a two-way oscillating brush system to safely, deeply cleanse the skin.

Another way to deal with milia is to undergo a periodic series of microdermabrasions or glycolic acid peels at the doctor's office. Maintenance is important. Unless you find your solution is throwing out some problem causing cream, you likely are in a situation where you will periodically continue to form new spots. So add in some gentle exfoliation into your grooming regimen.

Sometimes milia won't come out in spite of your best efforts. Then you may need the milia to be extracted by your dermatologist. In a physician's office, milia are easily removed. The skin is cleansed with some rubbing alcohol or other antiseptic. The skin overlying the milia is gently opened with a sterile lancet or needle. Then pressure is applied with a comedone extractor, and the milia typically pop out. I find that one of the most difficult areas from which to remove milia is the upper eyelid. There simply isn't a good way to press on the area and avoid the eyeball, so the lid has to be pulled either upwards or to the side, which is somewhat challenging.

I am always asked if a patient can remove milia by themselves at home. While removing milia is certainly not a technique that one must attend medical school to be able to do, it is rather difficult to remove your own milia. This is both from the mild self-inflicted discomfort as well as my concern that infection can arise if the procedure isn't performed properly. This means adequate skin cleansing as well as the use of sterile instruments. If you are going to give it a try, sterilize your needle and then after wiping the skin with rubbing alcohol, poke the milia and then press it out with the Tweezerman Skin Care Tool. Cleanse the area gently and if there is any bleeding, apply some hydrogen peroxide and a bandaid. Milia on the eyelids should be dealt with by your doctor!

What can you do to prevent milia? Besides keeping your lifelong sun exposure limited, wearing oil-free sunscreen such as DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body and using glycolic acid can help remove unwanted surface debris and cleanse the pores. Exfoliating cleanser options include DERMAdoctor Wrinkle Revenge Antioxidant Enhanced Glycolic Acid Facial Cleanser 2, DERMAdoctor Ain't Misbehavin' Medicated AHA/BHA Acne Cleanser and Peter Thomas Roth Glycolic Acid 3% Facial Wash. The addition of a topical treatment and help cell turnover and also complement a skin rejuvenation program. MD Formulations Continuous Renewal Serum is a light, water-based corrector works to refine surface skin and diminish the visible signs of aging. B. Kamins Glycolic 10 also uses glycolic acid and contains no oil or fatty acids. Cellex-C BetaPlex Line Smoother contains a 12% hydroxy acid blend in an oil-free gel.

Vitamin A creams also work effectively to exfoliate the skin, thin the epidermis and again fit nicely into a skin rejuvenation program. glo.therapeutics Tretinol 0.5%, and Afirm offers three levels of retinol for those starting a vitamin a routine. If you are using prescription Retin A, Renova, Differin, Avita or Tazorac for acne concerns or wrinkles, these can also be helpful in reducing your milia formation. Keep in mind that none of these vitamin A options should be applied to the eyelids.

You may enjoy using our Milia DERMAwizard which will provide you with a personalized product recommendation based on your answers to a few simple questions.

So if milia are the bane of your existence, don't worry. There's hope.

Thank you for taking the time to read my newsletter. As always, I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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