Milia guide: what they are, why they form, and how to get rid of them

Milia are among the most misunderstood skin lesions — frequently confused with whiteheads and targeted with pore-cleansing products that cannot address them. Here is the complete guide to what milia actually are and what works.

What milia are

Keratin cysts, not comedones

Milia (singular: milium) are epidermal inclusion cysts — small (1–2 mm), firm, white-to-yellow spherical lesions formed when shed keratinocytes (skin cells) accumulate beneath the skin surface in a trapped pocket rather than shedding normally.

Key distinction from comedones:
Whiteheads (closed comedones): Sebum + keratin + bacteria in a dilated follicle; a follicular opening exists; contents are semi-fluid
Milia: Pure keratin (no sebum) in a small cyst beneath the epidermis; no follicular opening; contents are firm/solid

Because milia have no connection to the skin surface, they cannot be "squeezed out" with pressure like a comedone — the cyst wall must be pierced for the keratin contents to be removed. This is why products targeting pores have no effect on milia.

---

Types of milia

Primary milia

Occur spontaneously without preceding skin injury or identifiable cause:
Neonatal milia: Extremely common in newborns — present in up to 50% at birth; self-resolve within weeks as the infant's exfoliation normalizes. No treatment needed.
Adult primary milia: Idiopathic; most common around the eyes (periorbital) and on the nose. Can persist for months to years without spontaneous resolution.
Milia en plaque: A rare variant — cluster of milia on a plaque-like base; seen in middle-aged women; may require dermatology evaluation.

Secondary milia

Arise following skin trauma or conditions that disrupt the normal epidermal barrier:
Post-blister milia: After bullous pemphigoid, porphyria cutanea tarda, or epidermolysis bullosa
Post-burn milia: After partial-thickness burns
Post-laser milia: Particularly after ablative laser (CO₂, Er:YAG) — a recognized adverse effect where re-epithelialization produces milia rather than normal surface architecture
Topical corticosteroid-associated milia: Chronic potent topical steroid use on the face can produce milia through epidermal thinning and abnormal keratinocyte behavior
Occlusion-associated milia: Heavy occlusive products (lanolin-heavy creams, certain ointments) may contribute to milia in susceptible individuals by trapping shed keratinocytes under the occlusive film

---

Why topicals cannot remove existing milia

The keratin cyst sits beneath an intact epidermis — there is no channel through which topical actives can dissolve or extract the cyst contents. Even aggressive exfoliants (20% glycolic acid, tretinoin) applied topically:
Work at the skin surface and upper epidermis
Cannot penetrate the full epidermis to reach a subcutaneous cyst
Cannot dissolve an intact keratin cyst wall from the outside

The only effective treatment for established milia is physical disruption — creating an opening in the epidermis and expressing or removing the cyst contents.

---

Treatment of established milia

Extraction (definitive treatment)

Professional extraction: A dermatologist or trained aesthetician uses a sterile lancet or comedone extractor (after sterile needle puncture) to express the keratinous contents. The procedure is brief, minimally painful, and produces immediate clearance. No topical product can replicate this.

Self-extraction: Not recommended — risk of scarring, secondary infection, and incomplete removal of the cyst wall (leading to recurrence). The periorbital area where milia commonly appear has particularly thin, delicate skin where amateur extraction causes significant bruising and trauma.

Electrodessication and curettage

For multiple persistent milia, a dermatologist may use light electrodessication to disrupt the cyst — particularly for milia en plaque or clustered milia not amenable to individual extraction.

Laser treatment

Ablative fractional laser (Er:YAG at low fluence) can vaporize milia — used for multiple milia in a single session with minimal surrounding tissue damage. Appropriate for patients with numerous milia or those in surgically challenging locations.

---

Prevention of new milia formation

Retinoids: the primary prevention strategy

Tretinoin, adapalene, and retinol normalize epidermal cell turnover — the dysregulated shedding that produces milia. With regular retinoid use:
Keratinocytes desquamate normally rather than accumulating in pockets
New milia formation is significantly reduced over months of use
Existing very new milia (early-stage, thin overlying epidermis) may resolve more rapidly

This is the strongest evidence-based preventive measure — retinoids address the root cause (abnormal epidermal turnover) rather than just treating existing lesions.

AHAs: surface exfoliation support

Regular AHA use (glycolic acid 5–10% or lactic acid 5–10%) accelerates surface desquamation — reducing the likelihood of shed cells being trapped beneath the surface. Less direct evidence for milia prevention than retinoids, but mechanistically relevant as an adjunct.

Product selection: avoiding occlusive contributors

Certain product types are associated with milia formation in susceptible individuals:
Heavy mineral oil-based moisturizers
Lanolin-heavy occlusives applied to the periorbital area
Comedogenic oils (coconut oil, palm oil) on areas prone to milia

Replacing these with lighter, non-comedogenic formulations (squalane, sodium hyaluronate serums, ceramide-based moisturizers) reduces the occlusion-associated milia risk.

---

When to see a dermatologist

Routine cases: Milia are benign — cosmetic concern only. If bothersome, dermatologist extraction is elective and low-risk.

Evaluate promptly if:
Milia appear in unusual locations (widespread distribution, not periorbital or nasal)
Associated with other skin findings: blistering, photosensitivity, skin fragility — may indicate an underlying condition (porphyria, epidermolysis bullosa)
Milia en plaque variant — histopathology warranted to rule out rare associations
Neonatal milia persisting beyond 3 months in an infant — evaluate for hereditary conditions

---

Looking for a skincare consultation or milia extraction? Browse med spa providers on MedSpot →