ISPUB.COM The Internet Journal of Dermatology Volume 7 Number 1 Azithromycin Therapy for Multiple Eruptive Milia: A Report of a Case, New Treatment Option, and Review of the Literature E McCarley O'Shea, A Mehta, A Levy, J Frey, R Skinner Citation E McCarley O'Shea, A Mehta, A Levy, J Frey, R Skinner. Azithromycin Therapy for Multiple Eruptive Milia: A Report of a Case, New Treatment Option, and Review. The Internet Journal of Dermatology. 2008 Volume 7 Number 1. Abstract This is a case report, new treatment option, and review of the literature of multiple eruptive milia in patients with no genetic predisposition for forming milia. We report a case of a 71 year-old female with multiple eruptive milia in bilateral axillae which greatly improved after three months of azithromycin therapy. Multiple eruptive milia are a rare phenomenon of unknown etiology with only nine reported cases in the literature. INTRODUCTION Eruptive milia is a unique entity defined in the literature as an outbreak of numerous milia that rapidly appear over weeks to months 1. These lesions differ from multiple primary milia that have slowly accumulated over time. Eruptive milia appear briskly, usually within one month, and are most frequently distributed on the head, neck, and trunk. Only nine cases of eruptive milia in patients aged eight to 78-years-old have been described in the English literature. Reports of effective treatment options for this idiopathic form of spontaneously arising milia are few. Incision and expression, curettage, and electrodessication all common treatments for limited numbers of milia are impractical for multiple eruptive milia due to the number of lesions and pain associated with treatment. Topical retinoids and minocycline have been suggested for milia en plaque, a rare variant of grouped milia forming a plaque often in the post-auricular area, but their use has not been reported for multiple eruptive milia. We report a case of multiple eruptive milia responsive to treatment with alternate weekly dosing of oral azithromycin. We also a present a review of cases of this rare entity. included only a multivitamin. She denied pre-existing skin conditions, trauma, infection, erythema or bites. Review of systems was unremarkable. Physical examination revealed a thin, elderly female with grouped 2-4mm flesh-colored to white dome-shaped noninflammatory papules grouped in bilateral axillae, her upper chest, and posterior neck (Figure 1). REPORT OF A CASE A 70-year-old female presented with a rapid onset of diffuse, intermittently pruritic lesions that started in bilateral axillae four months prior and subsequently spread to her upper chest and neck over the following three months. She had no significant past medical history. Her daily medicines 1 of 5
Figure 1 Figure 1: Multiple eruptive milia with cystic appearance in right axilla prior to azithromycin therapy. Figure 2 Figure 2: Hematoxylin and eosin stain shows an epitheliallined cyst in the reticular dermis consistent with milium. A punch biopsy confirmed the clinical diagnosis of milia (Figure 2). She was initially treated with oral minocycline 100mg twice daily, but was unable to tolerate this medication due to nausea. Minocycline was discontinued, and the patient was started on azithromycin 500mg on day one and 250mg on days two through five to be taken on the first and third week of the month, for three months. Three months later, the patient reported the lesions began to diminish in size after one month of azithromycin therapy. She had progressive clinical improvement and cessation of new lesion development at her eight month follow-up appointment (Figure 3). 2 of 5
Figure 3 Figure 3: Clinical improvement of milia after azithromycin treatment. Figure 4 Table 1: Reported Cases of Multiple Eruptive Milia. Clinical characteristics of each patient are described., Male;, Female A distinctive feature of our patient's eruption was the distribution of milia in bilateral axillae and chest with virtually no milia on the face. Unlike the case we present, the most common site of eruption is the face. Non-mechanical treatment options for multiple milia are limited and few successful treatments have been reported in the literature. Connelly described an 18-year-old female with eruptive milia of the chest who rapidly responded to Tretinoin 0.1%. 4 The response of our patient to azithromycin suggests the possibility of the presence of an infectious etiology for eruptive milia; however no such etiology has been found. Milia commonly occur secondary to inflammatory skin disease, and perhaps the antiinflammatory effect rather than the antimicrobial effect of azithromycin 10 prevented new milia from forming while established ones resolved. Comment. Milia have been divided into those arising spontaneously, inherited, or those associated with a genodermatosis. Langley et al suggested such a classification following a description of a case of multiple eruptive milia in a 71-year-old man with dermatitis, diabetes mellitus, and multiple malignancies and a review of the literature 2. Since then seven other cases have been described in the English literature (Table 1). References 1. James WD, Berger TG, Elston DM, eds: Epithelial Cysts and Sinuses. In: Andrews' Diseases of the Skin, Clinical Dermatology, 10th ed, Philadelphia, Pa: Saunders; 2006:680-1. 2. Langley RG, Walsh NM, Ross JB. Multiple eruptive milia: report of a case, review of the literature, and a classification. J Am Acad Dermatol. 1997; 37:353-60. 3. Diba, V, Handfield-Jones, S, Rytina, E, Hall P, Burrows N. Multiple Eruptive Milia in a 9 year old boy. Pediatric Dermatology. 2008; 24:474-476. 4. Connelley, Thomas; Eruptive Milia and Rapid Response to Tretinoin. Arch Dermatol. 2008; 144(6):816-817. 5. Diba VC, Al-Izzi M, Green T. A case of eruptive milia. Clin Exp Dermatol. 2005; 30:677-678. 6. Katayama I, Hirayama M, Eishi K. Basaloid follicular hamartoma with eruptive milia and hypohidrosis: is there a pathogenic relationship? Eur J Dermatol. 2003; 5:505-8. 7. Cairns, Michael L. M.D.; Knable, Alfred L. M.D. Multiple Eruptive Milia in a 15-year-old Boy. Pediatric Dermatology. 1999; 2:108-110. 8. Wolfe SF, Gurevitch AW. Eruptive milia. Cutis. 1997; 60:182-184. 9. Alapati U; Lynfield Y. Multiple Papules on the eyelids. Arch Dermatol. 1999; 135:1543-1548. 10. Scaglione F, Rossoni G. Comparative anti-inflammatory 3 of 5
effects of roxithromycin, azithromycin and clarithromycin. J Antimicrob Chemother. 1998 Mar; 41 Suppl B:47-50. 4 of 5
Author Information E. McCarley O'Shea, BS Anita Mehta, MD Division of Dermatology, Department of Medicine, Southern Illinois University Alan L. Levy, MD Jamie L. Frey, MD Robert B. Skinner, MD 5 of 5