By Jia Lissa 
Nearly 32 million Americans grapple with eczema, a chronic inflammatory skin condition, with atopic dermatitis being its most prevalent form. This condition manifests as dry, scaly, and intensely itchy patches of skin, and for a subset of individuals, its management can introduce a secondary dermatological concern: milia. These small, firm, keratin-filled bumps, typically white, yellow, or skin-toned, commonly appear around the eyes and on the cheeks. While various types of milia exist, individuals with inflammatory skin conditions such as eczema are particularly susceptible to what dermatologists term secondary, or traumatic, milia.
Dr. Dara Spearman, a board-certified dermatologist based in Fort Wayne, Indiana, explains that for these patients, milia emerge as a consequence of the persistent inflammation characteristic of eczema. This chronic inflammation compromises the skin’s natural barrier function and disrupts its shedding process for dead skin cells, leading to keratin becoming trapped beneath the skin’s surface. Furthermore, prolonged use of potent topical corticosteroids, a common treatment for eczema, can also impede skin cell turnover and contribute to skin thinning. "Thinner skin can be more prone to keratin becoming trapped under the surface, causing secondary milium," Dr. Spearman notes. The use of occlusive ingredients, such as petroleum jelly and shea butter, while beneficial for alleviating the dryness associated with atopic dermatitis, can also contribute to milia formation when applied excessively or on areas predisposed to these bumps.
This interplay between eczema and milia presents a significant challenge, particularly for aging individuals with darker skin tones. Dr. Spearman highlights, "As we age our skin loses moisture, and melanin-rich skin often has lower levels of lipids called ceramides, so this group tends to moisturize more. But when you use heavy oils or creams on the skin, you can form milia." This creates a delicate balancing act, where the very treatments used to soothe one condition can inadvertently exacerbate the other.
Understanding the Interplay: Eczema and Milia Formation
Eczema, scientifically known as atopic dermatitis, is characterized by a compromised skin barrier, which makes it more permeable and susceptible to irritants and allergens. This barrier dysfunction is often linked to genetic factors, environmental triggers, and an overactive immune response. The resulting inflammation leads to redness, itching, and the characteristic dry, scaly patches.
Milia, on the other hand, are essentially small cysts that form when keratin, a protein found in skin, hair, and nails, becomes trapped beneath the skin’s surface. Primary milia are common in newborns and usually resolve on their own. Secondary milia, however, develop as a result of skin damage or other underlying conditions. In the context of eczema, the chronic inflammation disrupts the normal process of keratinization and exfoliation. Inflammatory mediators can interfere with the follicular opening or the normal turnover of epidermal cells, leading to the entrapment of keratin.
The use of topical corticosteroids, while effective in reducing inflammation and itching associated with eczema, can also have unintended consequences. These potent medications can thin the epidermis and dermis over time, making the skin more delicate and potentially less efficient at shedding dead cells. This thinner, more vulnerable skin can then become a breeding ground for trapped keratin, contributing to the development of secondary milia.
Moreover, the common practice of using rich emollients and occlusive agents to combat the severe dryness and discomfort of eczema can also play a role. Ingredients like petrolatum, shea butter, and heavy oils create a barrier on the skin to prevent moisture loss. However, when applied too liberally, especially in areas where the skin’s texture is already compromised or prone to blockage, they can clog pores and hinder the natural expulsion of keratin, thereby fostering milia formation.
Addressing the Challenge: A Dual Approach to Treatment
Successfully managing both eczema and milia requires a nuanced, integrated approach that prioritizes stabilizing the skin barrier while gently addressing the milia without further compromising the compromised skin.
Optimizing Eczema Management for Milia Prevention
The cornerstone of managing co-occurring eczema and milia lies in effectively controlling eczema flares. When eczema is well-managed, the skin barrier begins to repair, creating a more stable environment that can facilitate the resolution of secondary milia.
Re-evaluating Topical Treatments: Patients experiencing both conditions should consult with their dermatologist to review their current eczema treatment regimen. If topical corticosteroids are prescribed, a discussion about transitioning to milder formulations may be warranted. "Depending on the severity of your condition, a less potent formula can still be strong enough to decrease the inflammation fueling your eczema, especially when paired with other lifestyle changes," Dr. Spearman explains. She also points to advancements in dermatological treatments, noting, "There are also some newer nonsteroidal anti-inflammatory creams that can treat the eczema without thinning the skin or causing milia." These alternatives offer a way to manage inflammation without the potential side effects of prolonged corticosteroid use.
Environmental and Lifestyle Adjustments: Environmental factors play a crucial role in eczema management. During drier months, using a humidifier can help maintain optimal skin hydration and prevent the exacerbation of eczema. Dr. Christina Lee Chung, a board-certified dermatologist in Philadelphia, emphasizes the importance of limiting exposure to water and heat, stating, "Shower for five minutes or less—just jump in and jump out." She further advises, "It’s better for your skin’s moisture levels to stick with lukewarm water and shower just once a day or even every other day, if possible." Prolonged exposure to hot water can strip the skin of its natural oils, worsening dryness and inflammation.
Cleanser Selection: The choice of cleanser is also critical. Dr. Spearman recommends using non-antibacterial cleansers on the majority of the body to preserve the skin’s natural moisture balance. "I always tell patients that if you want to use an antibacterial soap in hot spots like the groin or armpits, that’s fine. But on the rest of your body, use a non-antibacterial cleanser so you don’t strip extra moisture," she advises. She specifically praises Dove’s Soothing Relief body wash, formulated with colloidal oatmeal, which is known for its moisturizing and anti-itch properties. Its acceptance by the National Eczema Association further underscores its suitability for sensitive, eczema-prone skin.
Post-Shower Care: The period immediately following a shower is a critical window for moisture replenishment. Dr. Chung advises patting the skin dry gently and applying moisturizer while the skin is still slightly damp. This helps to lock in hydration. Both CeraVe’s Moisturizing Cream and Cetaphil’s Moisturizing Cream are highly recommended by Dr. Spearman, as they are also endorsed by the National Eczema Association for their efficacy in restoring and maintaining the skin’s moisture barrier.
For particularly dry or rough patches, emollients containing ingredients like petroleum jelly or shea butter may be necessary. However, Dr. Spearman advises moderation and strategic application. "Avoid using these products in areas where milia tends to pop up, and instead think of them as spot treatment for stubborn eczema patches." Aquaphor’s Moisturizing Cream is another product that has received the National Eczema Association’s seal of approval.
Targeting Milia Effectively
Once eczema is under better control, attention can shift to addressing the milia.
Dermatological Intervention: A dermatologist can manually extract milia using sterile instruments. While effective, this procedure carries a slight risk of scarring and infection, and thus requires professional execution.
Retinoid Therapy: Retinoids, derivatives of Vitamin A, are highly effective in treating milia. They work by promoting exfoliation and increasing skin cell turnover, which helps to prevent keratin from becoming trapped. "The caveat is that these milder formulations do take longer to [lead to] improvement, but it helps people stick to the routine when they are so well-tolerated," Dr. Spearman says of over-the-counter retinoid options. She recommends starting with milder formulations, such as Cocokind’s Advanced Retinol Gel, which is recognized by the National Eczema Association. Olay’s Regenerist Retinol 24 Starter Lotion is another option, though it does not carry the NEA seal.
It is crucial to note that retinoids can also cause dryness and irritation, potentially exacerbating eczema. To mitigate this, a careful approach is advised. Applying a light moisturizer before or after the retinoid can help the skin tolerate the treatment. The "sandwich method," involving layering moisturizer before and after retinoid application with a 10-minute waiting period between each product, is a strategy suggested by Dr. Spearman to maintain efficacy while minimizing irritation.
Considerations for Deeper Skin Tones: The use of retinoids warrants particular attention for individuals with darker skin tones. Dr. Chung explains, "People of color have a lot of melanocytes [the cells that make melanin]. When they have skin irritation, the melanocytes get irritated, too, and they do one of two things: They make more melanin, or they drop pigment, so you end up getting patches of lighter or darker skin." This means that retinoid-induced irritation, if not managed properly, can lead to post-inflammatory hyperpigmentation or hypopigmentation. Therefore, a meticulous skincare routine that prioritizes hydration and gentle application of retinoids is essential.
Broader Implications and Future Directions
The prevalence of co-occurring eczema and milia underscores the complex relationship between skin barrier health, inflammation, and keratinization processes. As research into the microbiome and its influence on skin conditions continues to advance, it is likely that more targeted therapies will emerge. Understanding the specific inflammatory pathways and cellular mechanisms involved in secondary milia formation in the context of eczema could lead to the development of novel treatments that address both conditions simultaneously without adverse effects.
For individuals experiencing these intertwined skin concerns, the key takeaway is that a solution exists. It requires patience, a willingness to collaborate closely with dermatological professionals, and a commitment to a tailored skincare regimen. By prioritizing eczema control, making informed choices about skincare products, and strategically incorporating treatments for milia, individuals can achieve clearer, healthier skin. The journey may involve some trial and error, but with the guidance of experts, a harmonious balance between managing eczema and resolving milia is attainable.
Additional reporting by Dana Leigh Smith
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