ARTICLE
A 44-year-old woman visited our dermatology clinic with asymptomatic
skin eruptions of one and a half-month's duration. There were numerous
(about 30), 1-2 mm, non-tender, hard, and pearly papules on each side
of the chin and on both sides of the mouth (Fig.
1A), where bullae had developed previously, three months earlier
as a result of Stevens-Johnson syndrome. The other areas involved in Stevens-Johnson
syndrome such as the nose and upper extremities were free of lesions.
A 2 mm punch biopsy was performed, and the histology of the lesion is
shown in Figure 2.
Grouped milia in an herpetiform
arrangement following Stevens-Johnson syndrome
The diagnosis was milia in an herpetiform arrangement, and histologic
examination of a lesion showed the characteristic findings of a milium
(Fig. 2). To remove the
numerous milia, about 60 in all, in a simple and rapid way, we used CO2
laser treatment, 2 watts/cm2, instead of conventional incision
methods such as No. 11 scalpel blade or a needle. The lesions were easily
expressed with a comedone extractor. Treatment was undertaken for cosmetic
purposes, and the result was remarkable (Fig.
1B).
Comments
Milia are considered to be epidermal cysts which arise from equipotential
cells anywhere in the cutaneous epithelial system. Two types are known:
primary or secondary milia [1]. The secondary type is reported to follow
various dermatoses including vesicobullous diseases [2], trauma [3] and
dermabrasion [4-5]. The pathogenesis of secondary milia is not yet fully
understood. Tsuji et al. [1] reported that 75.4% of secondary milia
following blistering arise from the eccrine sweat duct, 1.4% from the
hair follicle, and that the remaining 23.2% are not connected with any
skin appendages, presumably arising from aberrant epidermis. Our case
showed a milium which was connected with a hair follicle, and contained
cut portions of hair shaft (Fig.
2). Of interest in our case is the location of
the lesions. Despite the fact that the bullous lesion of Stevens-Johnson
syndrome had spread to most of the skin surface of this patient, only
the angular areas of her mouth were affected in an herpetiform arrangement.
We are not certain why this happened. We suggest that physical tension
might be an important factor inducing secondary milia. The perioral area
is notorious for developing hypertrophic scars
after dermatosurgical procedures. The reason is believed to be that there
is consistent muscle tension in that area as a result of the repetitive
distortion experienced in daily life. In fact, the skin near the angles
of the mouth is a site where continuous physical tension is produced as
a result of the action of facial expression muscles. All of the superficial
muscles of the face have their insertions into the overlying skin resulting
in pulling of the muscles, which causes the skin to fold or crease in
uniform patterns. Therefore, physical tension such as muscular stretching
may have been a contributory factor in our case.
REFERENCES
1. Tsuji T, Sugai T, Suzuki S. The mode of growth of eccrine duct milia.
J Invest Dermatol 1975; 65: 388-93.
2. Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, eds.
Dermatology in general medicine. 4th ed. Boston: McGraw Hill, Inc.,
1993: 868.
3. Ronchese F. Cicatrical comedones and milia. Arch Dermatol Syphiol
1950; 61: 498-500.
4. Iverson PC. Further development in the treatment of skin lesions
by surgical abrasion. Plastic Reconstr Surg 1953; 12: 27-40.
5. Monash S, Rivera RM. Formation of milia following abrasive treatment
for postacne scarring. Plastic Reconstr Surg 1953; 68: 589.
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