Section 2: Milia, Miliaria, and Pustular and Acneiform Disorders

Milia A milium is a white papule, 1 to 2 mm in size, composed of laminated, keratinous material and situated as a solid cyst in a pilosebaceous follicle. Milia are fairly common on the brow, glabella, and nose in newborn infants and in such infants tend to disappear quickly and spontaneously. There may be few or many, and they may develop later in infancy, in childhood, and in adolescence. In older children and adolescents, they tend to persist, may precede acne or be associated with incipient acne and commonly develop on or around the eyelids. Milia may be ablated, if desirable, by delicate incision and expression of the keratinous content. Lesions that are treated do not recur, but if new lesions appear, they have to be treated in the same way. The operation is trivial and uncomplicated. There are no preventive measures.

Eosinophilic pustular folliculitis of infancy Children with this rare disorder develop repeated crops of pruritic erythematous papules, yellow or white pustules, which vary in size from 1 to 3 mm. Most lesions are located on the scalp and distal extremities. Tzanck smear may reveal numerous eosinophils, and there may also be a peripheral eosinophilia when flaring. Eosinophilic pustular folliculitis is associated with no systemic symptoms and eventually resolves spontaneously. Therapy with topical steroids is beneficial.

Infantile acropustulosis This cutaneous disorder is characterized by recurrent episodes of intensely pruritic pustules and papulovesicles on the hands and feet. Lesions are most common on the palms and soles but may be seen on the dorsal surfaces as well.

Lesions may also occur on the ankles, forearms, and, rarely, the face, scalp, and upper trunk. The age at onset is typically between 2 and 10 months. Individual episodes last for 7 to 10 days and may recur as often as every 2 weeks at the beginning of the disease. Episodes tend to become less frequent and severe over time.

Infantile acropustulosis Stained smears of an individual lesion will reveal numerous neutrophils, although eosinophils may be present early in the course of the disorder. Infantile acropustulosis may also be seen after scabies infestation in infants (“postscabies syndrome”).

Figure 2-7 shows involvement of the forehead in a patient with infantile acropustulosis. The disease resolves spontaneously by 2 to 3 years of age. The individual lesions in this ...