Periocular skin is anatomically delicate and functionally complex, making dermatologic conditions in this region clinically significant. Comedones and milia are common benign follicular disorders that may occur around the eyelids and upper cheeks. Although often asymptomatic, their cosmetic impact and potential for misdiagnosis require careful clinical evaluation. This article reviews the anatomy of the periocular region, the pathophysiology of comedones and milia, clinical presentation, differential diagnosis, treatment modalities, procedural techniques for safe extraction, and prevention strategies.
Introduction
The periocular region contains some of the thinnest skin in the human body, measuring approximately 0.3–0.5 mm in thickness. It is rich in sebaceous glands, hair follicles, and specialized structures such as the glands of Zeis and Meibomian glands. These features predispose the area to follicular obstruction and keratin retention disorders.
Comedones and milia represent two common but distinct conditions that may present as small, dome-shaped or punctate lesions clustered around the eyelids and upper cheeks. While medically benign, their appearance often prompts patients to seek dermatologic or cosmetic treatment.
Anatomy of the Periocular Skin
Key characteristics include:
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Thin epidermis and dermis
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Reduced subcutaneous fat
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High density of pilosebaceous units
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Rich vascular and lymphatic supply
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Proximity to ocular structures
These factors increase susceptibility to irritation, scarring, infection, and post-inflammatory pigment changes following improper treatment.
Definitions
Comedones
Comedones are non-inflammatory acne lesions resulting from obstruction of the pilosebaceous unit. They are classified as:
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Open comedones (blackheads) – dilated follicles with oxidized keratin plugs
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Closed comedones (whiteheads) – small, skin-colored or whitish papules due to complete follicular occlusion
Milia
Milia are small, firm, white or yellow cysts composed of keratin trapped beneath the epidermis. Unlike comedones, they are not derived from hair follicles but from eccrine ducts or epidermal inclusion.
Pathophysiology
Comedone Formation
The development of comedones involves four main processes:
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Follicular hyperkeratinization
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Increased sebum production
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Obstruction of the follicular opening
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Bacterial colonization (secondary factor)
In the periocular area, occlusive cosmetics, heavy sunscreens, topical steroids, and inadequate cleansing can exacerbate this process.
Milia Formation
Milia arise from:
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Trapped keratin beneath the epidermis
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Skin trauma (secondary milia)
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Chronic topical steroid use
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Burns or blistering disorders
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Cosmetic procedures such as laser resurfacing or dermabrasion
Clinical Presentation
Periocular comedones and milia typically present as:
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Multiple, discrete, 1–3 mm papules
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White, yellow, or flesh-colored
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Non-tender and non-pruritic
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Often clustered on the lower eyelids, upper cheeks, and temples
In the provided image, multiple small follicular openings and keratin plugs are visible, with a sterile needle being used for controlled extraction.
Differential Diagnosis
Conditions that may mimic periocular comedones or milia include:
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Syringomas
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Xanthelasma palpebrarum
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Sebaceous hyperplasia
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Molluscum contagiosum
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Basal cell carcinoma (rare, nodular forms)
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Hidrocystomas
Accurate diagnosis is essential to avoid inappropriate treatment.
Diagnostic Approach
Diagnosis is primarily clinical and based on:
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Visual inspection
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Lesion morphology
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Distribution pattern
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Patient history (cosmetics, medications, trauma)
Dermoscopy may assist in ambiguous cases. Biopsy is rarely required unless malignancy is suspected.
Management Strategies
Conservative Management
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Discontinuation of comedogenic cosmetics
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Gentle facial cleansing
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Use of non-comedogenic moisturizers
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Sun protection
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Avoidance of topical corticosteroids near the eyes
Topical Therapy
For comedones:
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Topical retinoids (adapalene, tretinoin – used cautiously near eyes)
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Salicylic acid (low concentration)
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Azelaic acid
For milia:
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Limited response to topical agents
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Retinoids may prevent recurrence
Procedural Treatment
Manual Extraction
This is the most effective treatment for immediate lesion removal.
Technique:
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Skin cleansing with antiseptic solution
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Use of sterile gloves
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Superficial puncture with a sterile lancet or needle
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Gentle expression using comedone extractor or fingertips
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Hemostasis if required
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Application of topical antibiotic or soothing agent
Safety Considerations
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Avoid deep penetration to prevent scarring
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Use magnification for precision
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Maintain strict aseptic technique
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Avoid excessive pressure near the globe
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Contraindicated in patients with bleeding disorders or active infection
Other Options
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Electrodessication
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Laser therapy
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Chemical peels (superficial)
Complications
Improper extraction may lead to:
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Post-inflammatory hyperpigmentation
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Scarring
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Secondary bacterial infection
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Eyelid edema
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Contact dermatitis
Prognosis
Both comedones and milia are benign with excellent prognosis. Recurrence is common if predisposing factors persist. Long-term outcomes depend on adherence to skincare routines and avoidance of occlusive products.
Prevention
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Use oil-free, non-comedogenic cosmetics
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Remove makeup daily
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Avoid heavy eye creams
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Use sunscreen formulated for facial use
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Regular gentle exfoliation
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Avoid self-extraction in the periocular region
Conclusion
Periocular comedones and milia are common dermatologic conditions that pose minimal medical risk but significant cosmetic concern. Proper diagnosis, gentle management, and patient education are crucial to prevent complications. When procedural intervention is required, it should be performed by trained professionals using sterile technique due to the anatomical sensitivity of the eyelid region.
