If you have tiny, firm white bumps around your eyes or on your cheeks that never seem to go away or turn into a pimple, there is a good chance you are looking at milia.
I see milia (singular: milium) frequently in my treatment room, particularly around the eye area. They are harmless, but they can be persistent, and one of the biggest mistakes people make is treating them as if they were acne
On social media, I often see exfoliation recommended as a treatment for milia. Exfoliation will not remove an established milium. Because the keratin is enclosed beneath the surface of the skin, trying to exfoliate it away, particularly around the delicate eye area, can lead to unnecessary irritation, inflammation and barrier damage.
What Are Milia?
Milia are tiny cysts that form when keratin, a protein naturally found in the skin, becomes trapped beneath the surface.
They usually look like very small white or cream-colored pearls under the skin. Unlike a pimple, they generally aren't red, inflamed or painful. They can appear almost anywhere, but in adults I most commonly see them around the eyes and upper cheeks.
One individual cyst is technically called a milium. Milia is plural.
Why Do Milia Form?
Milia form when keratin becomes trapped beneath the surface of the skin instead of being shed normally. But when I see milia in the treatment room, I also want to understand why the skin may be prone to forming them in the first place.
Sometimes milia appear spontaneously, without an obvious trigger. They can also develop after the skin has been injured or disrupted, including after burns, blistering, rashes, significant sun damage or certain skin procedures.
I also look carefully at the products being used. Heavy, occlusive creams and ointments can contribute to milia formation in susceptible skin, particularly around the delicate eye area. If someone suddenly begins developing milia, I want to know whether they recently introduced a richer eye cream, balm, ointment or another highly occlusive product.
Essential fatty acids also play a role in normal follicular function and keratinization. When the skin is deficient in EFAs, normal shedding within the follicle can become disrupted, contributing to keratin retention and congestion. In my practice, this is one of the factors I consider when I see someone who is repeatedly developing milia or other forms of congestion.
Milia Are Not Whiteheads
This is probably the most common source of confusion.
A whitehead is acne. More specifically, a whitehead is a closed comedone, a follicle that has become clogged with sebum and keratin. An inflammatory pustule is different. It has a visible white or yellow center containing pus, usually with some redness around it, and it may be sensitive to the touch.
Milia are very different. They are keratin-filled cysts sitting beneath the surface of the skin.
That difference matters because you cannot treat every small white bump with acne products and expect it to disappear. Treating milia with acne products can lead to unnecessary irritation.
Milia, Closed Comedones, Pustules or Xanthelasma?
Several completely different lesions can look surprisingly similar at first glance.
Milia are typically tiny, firm, pearly white or cream-colored bumps. They are especially common around the eyes and upper cheeks and usually have no redness around them.
Closed comedones, or whiteheads, are clogged follicles. They tend to appear in acne-prone areas and often occur alongside other signs of congestion such as blackheads, pustules or breakouts. They are treated with acne products and protocols for congested skin.
Pustules generally have some degree of inflammation. You may see a white or yellow center containing pus with a pink or red halo around it. They may also be sensitive to the touch. They are treated with acne products and protocols for inflamed skin.
Xanthelasma is something entirely different. These are cholesterol-rich deposits in the skin that usually appear as yellowish, flat or slightly raised lesions around the eyelids, particularly toward the inner corners of the eyes. They can sometimes appear as smaller yellow bumps and be mistaken for milia.
Unlike milia, xanthelasma should NOT be extracted. If I see xanthelasma, I refer the client to a dermatologist, who can determine whether treatment is appropriate and, if so, which method may be suitable. Depending on the lesion, options may include electrocautery, laser, chemical treatment or surgical removal, although xanthelasma is not always successfully treatable and can recur after treatment. Because it can sometimes be associated with abnormal lipid levels, a physician may also recommend a lipid panel.
Location, color, texture and what else is happening in the surrounding skin all give us clues. But if a lesion doesn't behave the way you expect it to, don't keep attacking it with skincare. Have it properly identified.
Can You Extract Milia?
Yes! Because the keratin is enclosed beneath the skin, the surface generally needs to be carefully opened with a sterile lancet or needle before the contents can be removed.
You should not attempt to do this on your own. Please don't take a sewing needle to your face after watching someone do it online. Improperly opening the skin can cause inflammation, infection, pigmentation or scarring, particularly around the delicate eye area.
Professional extraction is quick when the lesion is appropriate for extraction and the person performing it knows what they are doing.
Can Skincare Get Rid of Milia?
Skincare cannot remove an established milium, but it can be useful for prevention and management.
Depending on the skin, controlled exfoliation can help normalize the accumulation and shedding of dead skin cells. Retinoids may also be appropriate in some cases to help normalize keratinization. Neither should be thought of as a way to exfoliate an existing milium away.
This distinction is especially important around the eyes, where people sometimes create an entirely new problem: irritation, dehydration and barrier damage while trying to eliminate a few tiny bumps.
So no, skincare cannot get rid of existing milia. But in some cases, an appropriate skincare routine may help reduce the factors contributing to their formation.
What I Look at When Someone Is Prone to Milia
When I see recurrent milia, I don't look only at the individual bumps. I look at the skin and the routine surrounding them.
Is the person using a very heavy eye cream?
Are they layering several rich products over the same area?
Are they exfoliating appropriately, or not at all?
Has there been inflammation, injury or another skin condition in the area?
Is this actually milia, or are we looking at closed comedones, pustules, xanthelasma or something else?
Only after a thorough assessment can we decide on the appropriate treatment.
The Bottom Line
Milia are common, benign and sometimes incredibly stubborn.
They aren't pimples, and treating them like pimples usually doesn't accomplish much. If you are prone to them, pay attention to overly occlusive products and make sure your skincare routine is appropriate for your skin. Established milia can be professionally extracted when necessary.
Most importantly, don't assume that every little white or yellow bump is the same thing.
