Acquired Milium in Children on Unusual Sites: Two Case Reports

Dear Madam, Milia are small-sized benign subepidermal cysts due to trapped keratin. These are characterized by pearly white-to-yellow color dome-shaped papular lesions of size 1 mm to 3 mm in diameter.[1] Milia may occur as either a primary or secondary lesion.[2] Primary milia appear spontaneously, which may be congenital or have onset later in life. Secondary milia develop after prior insult to the skin in the form of trauma, some chronic medications, and blistering disorders.[1] Milia commonly appear near cheeks and eyelids in areas of vellus hair follicles.[3] However, involvement of the nipple and penis are rare sites of involvement in children, with very few case reports in the literature. Case 1 A 3-year-old female child presented with a 1-year history of asymptomatic solitary papule on the right nipple without any history of prior trauma. On examination, there was a pearly white papular lesion of size 2 mm on the right nipple with normal surrounding skin [Figure 1a]. There was no induration, tenderness, discharge, or any sign of inflammation. The left side nipple was normal in appearance. The child had normal growth and development with complete vaccination as per her age. No other systemic abnormality was detected. Based on the clinical findings, differential diagnoses considered were molluscum contagiosum, juvenile xanthogranuloma, syringoma with milia-like structures, and trichoepithelioma. The dermoscopy showed a pearly white, rounded solid structure without branching vessels [Figure 1b]. A skin biopsy was not done, considering the future complications such as scarring and deformity of the nipple. The diagnosis of acquired milium was made based on clinical and dermoscopic findings.Figure 1: Pearly white papular lesion of size 2 mm–3 mm on the right nipple with normal surrounding skin (a). The dermoscopy showed a pearly white, rounded solid structure without branching vessels (b)Case 2 A 2-year-old male child presented with an asymptomatic single papule on glans penis for the last 3 months. On examination, there was a solitary pearly white dome-shaped papule with size 2mm, on the left lateral aspect of the glans without any change at the adjacent area of the penis and scrotal area [Figure 2a]. The child had undergone circumcision 1 year ago for religious reasons. Differentials considered were molluscum contagiosum, Fordyce spot, lichen nitidus, steatocystoma multiplex, and pearly penile papule.[3] Dermoscopy of the lesion showed a solid whitish structure without branching blood vessels [Figure 2b]. A diagnosis of acquired milium (secondary to circumcision) was made based on clinical and dermoscopic findings.Figure 2: Solitary pearly white dome-shaped papule with size 2mm-3mm, on the left lateral aspect of the glans without any change at the adjacent area of normal penile and scrotal skin (a). dermoscopy of the lesion showed a solid whitish structure (b)Acquired milia tend to be long-standing and usually need intervention, unlike congenital milia, which are often self-limited and disappear within 3–4 weeks.[1] In both cases, parents were counselled about the benign nature of the disease. Under topical anaesthesia, the milia of both cases were extracted with the help of 18 gauze needles without any complication [Figure 3]. While performing extirpation, white to yellow semisolid material came out from the cystic lesion, further favouring the diagnosis. We report these two cases for the unique and unusual location and uncommon age of presentation of milium.Figure 3: After removal of milia from the nipple (a), and glans (b)Declaration of patient consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.