MILIARIA HAND-OUT

1. DEFINITION
Miliaria is a common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity. Miliaria is thought to be caused by blockage of the sweat ducts, which results in the leakage of eccrine sweat into the epidermis or dermis.

2. EPIDEMIOLOGY
a. Worldwide, miliaria is most common in tropical environments, especially among people who recently moved to such environments from more temperate zones. Miliaria has been a significant problem for American and European military personnel who serve in Southeast Asia and the Pacific. b. Miliaria crystallina and miliaria rubra can occur in persons of any age, but the diseases are most common in infants. In a Japanese survey of more than 5,000 infants, miliaria crystallina was present in 4.5% of the neonates, with a mean age of 1 week. Miliaria rubra was present in 4% of the neonates, with a mean age of 11-14 days. c. Miliaria profunda is more common in adults than in infants and children.

3. ETIOLOGY
The following causes are recognized: a. Immaturity of the eccrine ducts: Neonates are thought to have immature eccrine ducts that easily rupture when sweating is induced; this rupture leads to miliaria. b. Occlusion of the skin, as with transdermal drug patches c. Occlusive clothing: Eighteen cases of miliaria rubra have been reported in US Army personnel who routinely wore flame-resistant army combat uniforms composed of a 65% rayon/25% Kevlar/10% nylon blend while serving in the hot, arid conditions of Afghanistan. d. Lack of acclimatization: Miliaria is common in individuals who move from a temperate climate to a tropical climate. The condition usually resolves after the individual has lived in the hot, humid conditions for many months. e. Hot, humid conditions: Tropical climates, incubators in neonatal nurseries, and febrile illnesses may precipitate miliaria. f. Exertion: Any stimulus to sweat may precipitate or exacerbate miliaria. g. Type I pseudohypoaldosteronism: This disorder of mineralocorticoid resistance leads to excessive loss of salt through eccrine secretions and is associated with repeated episodes of pustular miliaria rubra. h. Morvan syndrome: Miliaria rubra has been reported in this rare autoimmune disorder characterized by neuromyotonia, insomnia, hallucinations, pain, weight loss, and hyperhidrosis
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i. Drugs: Bethanechol, a drug that promotes sweating, has been reported to cause miliaria, as have clonidine and neostigmine. Isotretinoin, a drug that affects follicular differentiation, also has been reported to cause miliaria. A single case of miliaria crystallina following doxorubicin administration has been reported. j. Bacteria: Staphylococci are associated with miliaria, and antibiotics prevent miliaria in an experimental setting. k. Ultraviolet radiation: Some researchers found that miliaria crystallina preferentially occurs in UV-exposed skin.

4. ANATOMY & PHYSIOLOGY

Skin is divided into three layers: epidermis, dermis, and subcutaneous. Skin also has adnexal. Skin adnexal glands composed of skin, hair and nails. Skin glands located in the dermis layer, consisting of sebaceous glands and sudorifera/ sweat glands. There are two kinds of sweat glands, the eccrine glands are small, located in the superficial dermis with watery secretions, and larger apocrine glands, lies deeper and thicker secret. Eccrine glands, spiral duct and empties directly on the skin surface. eccrine sweat glands found all over the surface of the skin, but most are found on the palms of the hands, soles of the feet, forehead, and back.

5. PATHOGENESIS
Location of the blockage in the sweat duct determining miliary type, namely: a. Excessive Sweat and clothing that does not absorb sweat can cause blockages in the superficial stratum corneum and will produce miliaria crystalline. Channel is below the blockage broke and then raised vesicles as small white crystal clear. The top layer consists of the stratum corneum vesicles. b. Keratin blockage or due to Staphylococcus epidermidis in the sweat duct causes bubbles in the stratum spinosum and may break the skin causing inflammation of the skin. This process occurs in miliaria rubra, where the blockage little deeper, ie inside the epidermis. Usually characterized by erythema and itching. This manifestation arises due to vasodilatation and stimulation of receptors that cause itching by enzymes out of the cells of the epidermis because of sweat into the epidermis. c. Eruption of miliary rubra can be turned into a so-called miliaria pustulosa. d. If the blockage that occurs lie deeper, ie at the dermo-epidermal junction, vesicles occur in the superficial dermis. This process resulted in miliaria profunda are generally rare.

6. CLASSIFICATION
a. Miliaria crystallina
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b. Miliaria rubra c. Miliaria pustulosa d. Miliaria profunda

7. DIAGNOSIS
a. History 1. Miliaria crystallina This form usually affects neonates younger than 2 weeks and adults who are febrile or those who recently moved to a tropical climate. Lesions appear in crops within days to weeks of exposure to hot weather and disappear within hours to days. Lesions are generally asymptomatic. 2. Miliaria rubra This form usually affects neonates aged 1-3 weeks and adults who live in hot, humid environments. Lesions may occur under transdermal medication patches. Lesions may occur within days of exposure to hot conditions, but they tend to appear after months of exposure. Lesions resolve within days after the patient is removed from the hot, humid environment. Lesions cause intense pruritus and stinging that is exacerbated by fever, heat, or exertion. Patients may report fatigue and heat intolerance, and they may notice decreased or absent sweating at the affected sites. 3. Miliaria pustulosa The miliary form occurs in individuals who have suffered repeated attacks miliaria rubra, and often occurs in tropical climates. Usually there is a history of ever suffered from contact dermatitis, lichen simplex chronicus, and intertrigo. 4. Miliaria profunda This form occurs in individuals who usually live in a tropical climate and have had repeated episodes of miliaria rubra. Lesions develop within minutes or hours after the stimulation of sweating. These lesions resolve quickly, usually in less than an hour after the stimulus that causes sweating is removed. The lesions are asymptomatic. Patients may report increased sweating in unaffected skin; swollen lymph nodes; hyperpyrexia; and symptoms of heat exhaustion, which include dizziness, nausea, dyspnea, and palpitations. b. Physical examination 1. Miliaria crystallina

Lesions are clear, superficial vesicles that are 1-2 mm in diameter. Lesions occur in crops and are often confluent, without any surrounding erythema. In infants, lesions tend to occur on the head, neck, and upper part of the trunk. In adults, lesions occur on the trunk. Lesions rupture easily and resolve with superficial branny desquamation. 2. Miliaria rubra Lesions are uniform, small, erythematous papules and vesicular papules on a background of erythema. Lesions occur in a nonfollicular distribution and do not become confluent. In infants, lesions occur on the neck and in the groin and axillae. In adults, lesions occur on covered skin where friction occurs; these areas include the neck, scalp, upper part of the trunk, and flexures. The face and volar areas are spared. In late stages, anhidrosis is observed in affected skin. 3. Miliaria pustulosa Deep white papules Looks erythema vesicles containing pus (pustules) 4. Miliaria profunda Lesions are firm, flesh-colored, nonfollicular papules that are 13 mm in diameter. Lesions occur primarily on the trunk, but they can also appear on the extremities. Lesions are transiently present after exertion or other stimulus that results in sweating. Affected skin shows diminished or absent sweating. In severe cases that lead to heat exhaustion, hyperpyrexia and tachycardia may be observed. c. Histologic Findings 1. In miliaria crystallina, intracorneal or subcorneal vesicles communicate with eccrine sweat ducts, without surrounding inflammatory cells. Obstruction of the eccrine duct may be observed in the stratum corneum. 2. In miliaria rubra, spongiosis and spongiotic vesicles are observed in the stratum malpighian, in association with eccrine sweat ducts. Periductal inflammation is present. 3. In early lesions in miliaria profunda, a predominantly lymphocytic periductal infiltrate is present in the papillary dermis and lower epidermis. A PAS-positive diastase-resistant eosinophilic cast may be seen in the ductal lumen. In later lesions, inflammatory cells may be present lower in the dermis, and lymphocytes may enter the

eccrine duct. Spongiosis of the surrounding epidermis and parakeratotic hyperkeratosis of the acrosyringium may be observed.

8. DIFFERENTIAL DIAGNOSIS
a. Varicella 1. The varicella-zoster virus (VZV) is the etiologic agent of the clinical syndrome of chickenpox (varicella). Chickenpox is largely a childhood disease, with more than 90% of cases occurring in children younger than 10 years. The disease is benign in the healthy child, and increased morbidity occurs in adults and immunocompromised patients 2. The characteristic chickenpox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal 3. Chickenpox is clinically characterized by the presence of active and healing lesions in all stages of development within affected locations. Lesions characteristically heal without scarring, although excoriation or secondary bacterial superinfection predisposes to scar formation. b. Candidiasis 1. Cutaneous candidiasis and other forms of candidosis are infections caused by the yeast Candida albicans or other Candida species. 2. Neonates and adults aged over 65 years are most vulnerable to this candida colonization. 3. Infections of the skin folds, especially in obese people, a typical erythematous, slightly damp, began in the crease area, irregular edges. Classic shape with satellite lesions, vesicles, pustules, and papules, which if broken would happen erosion. Can be accompanied by pain and intense itching. c. Folliculitis 1. Folliculitis is defined histologically as the presence of inflammatory cells within the wall and ostia of the hair follicle, creating a follicular-based pustule. 2. Folliculitis can be seen in persons of all ages. d. Herpes simplex 1. Herpes simplex viruses (HSVs) are DNA viruses that cause acute skin infections and present as grouped vesicles on an erythematous base. 2. HSV-1 infection is transmitted through saliva, and generally found in children, although the primary herpes gingivostomatitis can be observed at any age. 3. HSV-2 infection is transmitted through the content (of the mother at birth episode) and sexually transmitted 4. Clinical symptoms of grouped vesicles and pustules on an erythematous plaque fibers edema. There is enlargement of the
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regional lymph nodes, but fever and constitutional symptoms are usually mild.

9. TREATMENT
a. Education 1. Patients who have had miliaria, especially miliaria profunda, must be aware of the role of heat and humidity in precipitating this condition. 2. These patients should be advised to wear lightweight clothing, stay out of the sun, avoid exertion in hot weather, and stay in an airconditioned environment as much as possible. b. Topical Therapy 1. Salicylic powder 2% spiked with menthol % -2% 2. Faberi lotion with a composition of salicylic acid, talcum powder, zinc oxyd, amylum oryzae, spirits, and menthol 3. For miliaria profunda, calamine lotion can be given with or without menthol 0.25%, may also resorsin 3% in alcohol. 4. Topical corticosteroid 5. Lanolin anhidrat 6. Benzoil peroksida soap c. Systemic Therapy 1. Antibiotic prophylaxis 2. Ascorbat acid 500 mg, 2 X 1 3. Antipruritus or antihistamines (AH1) such as chlorpheniramine or bromfeniramin 4-8 mg every 4-6 hours 4. Aromatic retinoids such as isotretinoin 0.5 mg/kg

10.COMPLICATIONS
a. The most common complications of miliaria are secondary infection and heat intolerance. b. Secondary infection may appear as impetigo or as multiple discrete abscesses known as periporitis staphylogenes. c. Heat intolerance is most likely to develop in patients with miliaria profunda; it is recognized by anhidrosis of the affected skin, weakness, fatigue, dizziness, and even collapse. In its most severe form, this heat intolerance is known as tropical anhidrotic asthenia.

11.PROGNOSIS
Most patients recover uneventfully within a matter of weeks, once they move to a cooler environment.