It’s Not a Whitehead, It’s Milia—Here’s How to Treat It

Imagine waking up to discover tiny, pearly white bumps speckling your skin, often around the delicate eye area, nose, or cheeks. Your immediate thought might be “whiteheads,” those familiar adversaries of clear skin. Yet, what if these aren’t the typical breakouts you’ve come to know? This common misidentification often leads to ineffective or even damaging self-treatment. In reality, these stubborn little bumps are likely milia, distinct keratin cysts that demand a different, more nuanced approach than traditional acne.

Understanding Milia: More Than Just a Pimple

Milia are small, white or yellowish, dome-shaped cysts that form just beneath the surface of the skin. Unlike acne, they are not caused by clogged pores filled with oil and bacteria. Instead, milia are keratin-filled cysts, meaning they are tiny pockets of trapped dead skin cells and keratin, a protein that forms the outer layer of skin, hair, and nails. They are typically asymptomatic, meaning they don’t cause pain, itchiness, or inflammation.

Milia vs. Whiteheads: A Crucial Distinction

The distinction between milia and whiteheads (closed comedones) is paramount for effective treatment. While both appear as small, white bumps, their underlying causes and characteristics differ significantly.

Cause: Whiteheads result from a pore being clogged with excess oil (sebum), dead skin cells, and bacteria. Milia, on the other hand, are formed when dead skin cells or keratin become trapped under a new layer of skin, creating a small cyst.
Appearance and Feel: Milia are generally firmer to the touch and typically smaller, around 1-2 mm in diameter. They do not have an opening to the skin’s surface, making them difficult, if not impossible, to “pop.” Whiteheads are usually softer and may have some redness or inflammation around them.
Location: While both can appear on the face, milia are particularly common around the eyes, eyelids, nose, and cheeks. Whiteheads often occur in oilier areas like the forehead and chin.
Pus/Secretion: Milia do not contain pus or sebum, only trapped keratin. Whiteheads, being a form of acne, can sometimes be expressed, releasing a plug of sebum and dead cells, though this is not recommended for self-treatment.

Common Causes and Risk Factors for Milia

Milia can affect individuals of all ages, from newborns to adults. Several factors can contribute to their formation:

Trapped Keratin: The primary cause is when dead skin cells don’t shed properly and become trapped beneath the surface of the skin, forming a cyst.
Skin Damage: Secondary milia (also known as traumatic milia) can develop after skin injuries such as burns, rashes, blistering conditions (like poison ivy), or excessive sun exposure. Skin resurfacing procedures, like dermabrasion or laser resurfacing, can also sometimes lead to their formation.
Thick or Heavy Skincare Products: Using heavy creams, ointments, or comedogenic (pore-clogging) makeup can interfere with the skin’s natural exfoliation process, trapping keratin and contributing to milia.
Long-Term Steroid Use: Prolonged use of steroid creams has been identified as a cause of milia.
Genetics: Some individuals may be genetically predisposed to developing milia, and certain rare inherited conditions can cause juvenile milia.
Lack of Proper Skin Care: Inadequate cleansing or exfoliation can lead to a buildup of dead skin cells, increasing the risk.
Sun Exposure: Excessive sun exposure can make the skin leathery, hindering its natural shedding process and trapping keratin.

Different Types of Milia

While often generalized, milia present in several forms, each with unique characteristics:

Neonatal Milia: Found in about 40-50% of healthy newborns, typically appearing on the nose, chin, forehead, and cheeks. These are present at birth and usually resolve on their own within a few weeks without treatment.
Primary Milia: These cysts can appear on children and adults, most commonly on the face, particularly around the eyelids, forehead, cheeks, and even genitals. They form directly from entrapped keratin and may persist for months or years.
Secondary/Traumatic Milia: Develop in areas of skin damage or trauma, such as burns, blisters, or after certain skin procedures.
Juvenile Milia: A rare type associated with inherited genetic conditions, sometimes present at birth or appearing later in life.
Milia en Plaque: A rare condition where milia cluster together on a raised, inflamed patch of skin. It often affects women between 40 and 60, commonly behind the ears, on eyelids, cheeks, or jaw.
Multiple Eruptive Milia: Characterized by groups of itchy cysts appearing over weeks to months, typically on the face, upper arms, and upper abdomen.

Effective Milia Treatment Strategies

Given that milia are not typical acne, attempting to squeeze or pop them is strongly discouraged. This can lead to skin damage, infection, bleeding, and permanent scarring, as there’s no pore opening to expel the trapped keratin. Instead, treatment focuses on promoting skin cell turnover and, if necessary, professional extraction.

At-Home Milia Treatment Options

For mild cases of milia, particularly primary milia in adults, several at-home strategies can help encourage natural resolution or prevent new formations:

Gentle Cleansing: Wash your face daily with a mild, gentle cleanser and warm water to remove dirt, oil, and sweat. Pat your skin dry gently.
Steam Treatments: Steaming your face can help soften the skin and encourage trapped keratin to loosen. You can achieve this by sitting in a bathroom with a hot shower running or using a bowl of warm water.
Targeted Exfoliation: Gentle chemical exfoliation can help shed old skin cells and prevent keratin from getting trapped. Look for over-the-counter products containing alpha hydroxy acids (AHAs) like glycolic acid or lactic acid, or beta hydroxy acids (BHAs) like salicylic acid. Start by using these products once or twice a week to avoid irritation, and gradually increase frequency as tolerated.
Topical Retinoids: Over-the-counter retinoids (like retinol) or prescription-strength retinoids (like adapalene gel or tretinoin cream) can be highly effective. These vitamin A derivatives accelerate cell turnover and promote the natural shedding of skin cells, helping to bring trapped keratin to the surface. If you’re new to retinoids, start with a lower strength and use it a few times a week, increasing as your skin adapts.
Lightweight Sunscreen: Regular use of a broad-spectrum sunscreen with an SPF of 30 or higher, even on cloudy days, is crucial. Sun exposure can thicken the skin, making it harder for dead cells to shed and increasing milia formation. Choose a light, non-comedogenic (non-pore-clogging) formula.
Avoid Heavy Creams and Oils: Opt for lighter, non-greasy moisturizers and avoid heavy, occlusive creams or ointments that can clog pores and exacerbate milia.
Patience is Key: At-home treatments can take several weeks to months to show results. Milia often resolve on their own, especially in infants.

Professional Milia Removal

When at-home methods are insufficient, or for persistent, widespread, or cosmetically bothersome milia, professional treatment by a dermatologist is the safest and most effective option. Dermatologists have the expertise and sterile tools to remove milia without causing scarring or infection.

Common professional milia removal techniques include:

Manual Extraction (De-roofing): This is the most reliable and immediate way to remove milia. A dermatologist uses a sterile needle or small blade to create a tiny opening in the top of the milium and then gently extracts the keratin plug, often with a comedone extractor. The procedure is typically quick and causes minimal discomfort, often described as a slight prick.
Chemical Peels: Superficial chemical peels, usually containing glycolic acid or salicylic acid, can effectively treat and prevent milia by removing the top layer of dead skin cells and promoting exfoliation. These professional peels penetrate deeper than over-the-counter options.
Cryotherapy: This involves freezing the milia with liquid nitrogen, causing the cysts to blister and then subside. This method should be used with caution, particularly in individuals with darker skin tones, due to the risk of hypopigmentation.
Laser Ablation/Resurfacing: Lasers can be used to precisely target and remove the outer layers of skin, effectively eliminating milia, especially for clusters.
Electrocautery: This procedure uses heat generated from an electric current to destroy the milia, causing them to form a scab and then subside.
Prescription Medications: For certain types of milia, a dermatologist might prescribe stronger topical retinoids or, in rare cases like Milia en Plaque or Multiple Eruptive Milia, oral antibiotics such as minocycline.
Microdermabrasion: This gentle mechanical exfoliation technique buffs away the outermost layer of dead skin cells, helping to prevent keratin buildup.

Preventing Future Milia Outbreaks

While not all types of milia are preventable, especially neonatal milia, adults can significantly reduce their risk of developing new bumps through consistent and appropriate skincare practices.

Consistent Skincare Routine: Regularly cleanse your face twice a day with a gentle, non-comedogenic cleanser to prevent dirt, oil, and sweat buildup that can lead to clogged pores and trapped keratin.
Gentle Exfoliation: Incorporate gentle exfoliation (chemical or physical) into your routine 2-3 times a week to promote healthy skin cell turnover and prevent dead cells from accumulating. Avoid over-exfoliating, as this can irritate the skin.
Daily Sun Protection: Use a broad-spectrum sunscreen with SPF 30+ every day, regardless of weather, to protect your skin from sun damage that can thicken the skin and hinder exfoliation.
Choose Non-Comedogenic Products: Opt for skincare products, moisturizers, and makeup labeled “non-comedogenic” to ensure they won’t clog your pores.
Avoid Heavy, Occlusive Creams: Steer clear of very thick or heavy creams and ointments, particularly around areas prone to milia, as they can trap dead skin cells.
Proper Use of Medications: If prescribed steroid creams, use them only as directed by your doctor and avoid long-term or excessive use, which can contribute to milia.
Thorough Makeup Removal: Always remove all makeup before bed to allow your skin to breathe and properly shed dead cells.

By understanding the nature of milia and adopting appropriate treatment and prevention strategies, you can effectively manage these tiny, pearly bumps and work towards achieving smoother, clearer skin. If you are unsure about bumps on your skin or if milia are persistent and bothersome, always consult with a board-certified dermatologist for an accurate diagnosis and personalized treatment plan.