0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation |

In Vivo Imaging of Miliaria Profunda Using High-Definition Optical Coherence Tomography Diagnosis, Pathogenesis, and Treatment FREE

Hong Liang Tey, MRCP1; Evelyn Yuxin Tay, MRCP1; Taige Cao, MBBS1
[+] Author Affiliations
1National Skin Centre, Singapore
JAMA Dermatol. 2015;151(3):346-348. doi:10.1001/jamadermatol.2014.3612.
Text Size: A A A
Published online

Miliaria profunda (MP) is a condition of sweat duct obstruction manifesting with generalized papular eruption and anhidrosis.1,2 Using imaging with high-definition optical coherence tomography (HD-OCT), we identified, in vivo, the depth of lesions in MP and the likely location of sweat duct obstruction. To our knowledge, this is the first time such an evaluation has been performed.

REPORT OF CASES

Case 1

A man in his 30s presented with generalized anhidrosis for 5 months. When his body temperature was increased, “goose-bumps” appeared over his trunk and limbs, which resolved spontaneously within an hour of cooling. Findings of baseline skin imaging using HD-OCT (Skintell; Agfa Healthcare) were normal. However, after exercise testing extensive whitish papules appeared over his trunk and limbs (Figure 1). Starch-iodine testing revealed generalized anhidrosis.

Place holder to copy figure label and caption
Figure 1.
Generalized Anhidrosis on the Back of a Patient With Miliaria Profunda

A, Asymptomatic, nonfollicular whitish papules developed over the skin during active exercise. B, An admixture of starch-iodine powder was sprayed over the whole body after exercise using pressurized air through a spray gun, revealing generalized anhidrosis except for very limited areas (stained purple) on the lower back.

Graphic Jump Location

Testing with intradermal carbachol, 0.01% at 1 mL (Miostat; Alcon Laboratories Inc), failed to stimulate sweat production in our patient, although it did stimulate sweat production in 5 age- and sex-matched controls. Visualization with HD-OCT was repeated at the previous locations after exercise testing, now with whitish papules present (Figure 2). Biopsy of a whitish papule revealed epidermal spongiosis and hyperkeratosis over the sweat orifice.

Place holder to copy figure label and caption
Figure 2.
High-Definition Optical Coherence Tomography Features of Miliaria Profunda

A, The intraepidermal nature of the skin papule is demonstrated. Converging lines indicate the same location on slice and en face views. The lumen of the acrosyringium (within the circles) is enlarged, and adjacent hyperrefractile (bright) areas represent macerated keratin. On the en face view, a hyporefractile (dark) rim likely represents free fluid. Another skin papule can be observed at the lower left. B, Three-dimensional reconstruction using ImageJ (National Institutes of Health) and Imaris (Bitplane) demonstrating the location of the skin papules (yellow circles) at skin creases where sweat orifices are concentrated. C, When the dermis was digitally removed and the image flipped over, the lesions (red circles) were demonstrated to lie in the epidermis.

Graphic Jump Location

Aluminum hexachloride was applied to an age-, sex- and ethnicity-matched healthy volunteer’s chest, and serial HD-OCT images were taken daily. The aluminum salt was found in the sweat orifices in this healthy control, and underlying intraepidermal changes similar to the patient’s MP lesions developed.

Ultimately, isotretinoin, 10 mg 3 times per week, was prescribed for our patient. Three months later, a repeated exercise starch-iodine test revealed marked increased areas of sweating. Analysis of pixel color in pretreatment and posttreatment images revealed that hidrotic areas on the trunk (that were most important in lowering core body temperature) had increased from 8.4% to 92.6%.

Case 2

A man in his 20s developed MP as he was recovering from widespread pityriasis rosea. His HD-OCT findings were very similar to those in case 1. He opted for conservative management.

DISCUSSION

The term miliaria profunda was coined to refer to the deeper level of sweat duct obstruction, at or below the dermoepidermal junction, in contrast to the superficial and deeper epidermis locations in miliaria crystallina and miliaria rubra, respectively.2 This location of sweat duct obstruction in MP was determined experimentally in a healthy volunteer whose terminal sweat ducts were destroyed using electrolysis.2

Evaluation with HD-OCT in both of our patients localized the skin lesions to the epidermis. Dilated spiraling acrosyringium was identified, and the adjacent hyperrefractile (bright) substance likely represents macerated keratin (Figure 2), which can be correlated with the poorly demarcated whitish papules observed clinically and on dermoscopy. The lesions were also surrounded by a hyporefractile (dark) rim, which likely represents free fluid (water has a low refractive index) consequent to obstructed sweat outflow and correlating with the spongiosis observed in histologic analysis. This phenomenon was better observed via in vivo imaging than histologic analysis likely because of the dehydration process used in histologic slide preparation.

Aluminum hexachloride applied to a healthy volunteer to experimentally obstruct the sweat orifices produced HD-OCT changes similar to those seen in MP. In previous reports,24 surface hyperkeratosis and parakeratosis of acrosyringium have been noted, but these were postulated to be only an epiphenomenon. We also identified these hyperkeratotic plugs in our histologic analysis, and by correlating histologic with HD-OCT findings, we determined that the obstruction most likely occurred at the sweat orifices due to these hyperkeratotic plugs. Such plugs can occur subsequent to inflammatory skin diseases5 such as pityriasis rosea (case 2). Patient 1 was treated with isotretinoin because retinoids are known to reduce hyperkeratinization.6 The marked response to isotretinoin in patient 1 further supports the important role of hyperkeratinization in the pathogenesis of MP.

Miliaria profunda can be effectively diagnosed using HD-OCT. Contrary to current belief, the evanescent skin papules are intraepidermal, and hyperkeratotic plugs at the sweat orifices are the likely cause of obstruction. We hereby propose that MP be renamed miliaria alba, following the pattern of the clinically descriptive names for miliaria crystallina and miliaria rubra.

ARTICLE INFORMATION

Corresponding Author: Hong Liang Tey, MRCP, National Skin Centre, Singapore, 1 Mandalay Rd, Singapore 308205 (teyhongliang111@yahoo.com).

Published Online: November 12, 2014. doi:10.1001/jamadermatol.2014.3612.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Shunjie Chua, BEng, for his assistance in data collection.

REFERENCES

Fox  EC.  Tropical anhidrotic asthenia: thermogenic anhidrosis. Arch Derm Syphilol. 1949;60(2):173-180.
PubMed   |  Link to Article
Shelley  WB.  Experimental miliaria in man: IV, sweat retention vesicles following destruction of terminal sweat duct. J Invest Dermatol. 1951;16(1):53-64.
PubMed
Sulzberger  MB, Harris  DR.  Miliaria and anhidrosis. 3. Multiple small patches and the effects of different periods of occlusion. Arch Dermatol. 1972;105(6):845-850.
PubMed   |  Link to Article
Kirk  JF, Wilson  BB, Chun  W, Cooper  PH.  Miliaria profunda. J Am Acad Dermatol. 1996;35(5, pt 2):854-856.
PubMed   |  Link to Article
Haque  MS, Hailu  T, Pritchett  E, Cusack  CA, Allen  HB.  The oldest new finding in atopic dermatitis: subclinical miliaria as an origin. JAMA Dermatol. 2013;149(4):436-438.
PubMed   |  Link to Article
Elias  PM.  Epidermal effects of retinoids: supramolecular observations and clinical implications. J Am Acad Dermatol. 1986;15(4, pt 2):797-809.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Generalized Anhidrosis on the Back of a Patient With Miliaria Profunda

A, Asymptomatic, nonfollicular whitish papules developed over the skin during active exercise. B, An admixture of starch-iodine powder was sprayed over the whole body after exercise using pressurized air through a spray gun, revealing generalized anhidrosis except for very limited areas (stained purple) on the lower back.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
High-Definition Optical Coherence Tomography Features of Miliaria Profunda

A, The intraepidermal nature of the skin papule is demonstrated. Converging lines indicate the same location on slice and en face views. The lumen of the acrosyringium (within the circles) is enlarged, and adjacent hyperrefractile (bright) areas represent macerated keratin. On the en face view, a hyporefractile (dark) rim likely represents free fluid. Another skin papule can be observed at the lower left. B, Three-dimensional reconstruction using ImageJ (National Institutes of Health) and Imaris (Bitplane) demonstrating the location of the skin papules (yellow circles) at skin creases where sweat orifices are concentrated. C, When the dermis was digitally removed and the image flipped over, the lesions (red circles) were demonstrated to lie in the epidermis.

Graphic Jump Location

Tables

References

Fox  EC.  Tropical anhidrotic asthenia: thermogenic anhidrosis. Arch Derm Syphilol. 1949;60(2):173-180.
PubMed   |  Link to Article
Shelley  WB.  Experimental miliaria in man: IV, sweat retention vesicles following destruction of terminal sweat duct. J Invest Dermatol. 1951;16(1):53-64.
PubMed
Sulzberger  MB, Harris  DR.  Miliaria and anhidrosis. 3. Multiple small patches and the effects of different periods of occlusion. Arch Dermatol. 1972;105(6):845-850.
PubMed   |  Link to Article
Kirk  JF, Wilson  BB, Chun  W, Cooper  PH.  Miliaria profunda. J Am Acad Dermatol. 1996;35(5, pt 2):854-856.
PubMed   |  Link to Article
Haque  MS, Hailu  T, Pritchett  E, Cusack  CA, Allen  HB.  The oldest new finding in atopic dermatitis: subclinical miliaria as an origin. JAMA Dermatol. 2013;149(4):436-438.
PubMed   |  Link to Article
Elias  PM.  Epidermal effects of retinoids: supramolecular observations and clinical implications. J Am Acad Dermatol. 1986;15(4, pt 2):797-809.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

742 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
Jobs