Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – cool environment plus supportive care

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ACUTE
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all patients
1st line – 

cool environment plus supportive care

Overall, the only effective treatment and prevention is to avoid further sweating.[7] In the setting of miliaria crystallina, a few hours in a cool environment will often bring relief.[10]

However, complete treatment of miliaria profunda can take avoidance of heat for weeks to months.[39]

Cool soothing baths with addition of colloidal oatmeal can be a helpful adjunct to soothe the skin.[38]

Supportive care includes application of moisturising ointments such as anhydrous lanolin (applied before exercise or at onset of eruption and when required), regular cleansing of the skin, topical cornstarch powder (applied before exposure to hot/humid conditions and when required to treat eruption) or other absorbent powders, and ascorbic acid (vitamin C). Oral ascorbic acid is effective in the prevention and treatment of miliaria.[44] ​Topical treatment, such as chlorhexidine, may be added to a supportive care regimen.

Primary options

cool environment, moisturising ointment, topical absorbent powder and cleansing

and

ascorbic acid: children and adults: 1 g orally once daily

Secondary options

cool environment, moisturising ointment, topical absorbent powder and cleansing

and

ascorbic acid: children and adults: 1 g orally once daily

and

chlorhexidine topical: (2% to 4%) apply to the affected area for 15 seconds and rinse

Consider – antibacterial agents

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ACUTE
|
all patients
Consider – 

antibacterial agents

Additional treatment recommended for SOME patients in selected patient group

Because of the possible causative role of Staphylococcus epidermidis in all forms of miliaria, topical antibacterials are another consideration especially for prophylaxis in at-risk patients.[18]

Topical antibacterials used in studies include bacitracin, chloramphenicol, erythromycin, neomycin, polymyxin, and chlorhexidine.

These antibacterials, when used prophylactically, reduced the formation of experimentally induced miliaria.[18][39][40] However, their use in the treatment of established miliaria has not been clearly demonstrated.[1][18]

Primary options

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to three times daily

OR

bacitracin/neomycin/polymyxin B/pramoxine topical: apply to the affected area(s) two to three times daily

OR

bacitracin/polymyxin B topical: apply to the affected area(s) two to three times daily

OR

erythromycin topical: apply to the affected area(s) twice daily

OR

neomycin/polymyxin B/pramoxine topical: apply to the affected area(s) two to three times daily

Plus – antipyretics

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ACUTE
|
all patients
|
febrile patients
Plus – 

antipyretics

Treatment recommended for ALL patients in selected patient group

Used to lower the temperature of a febrile patient with miliaria (especially miliaria crystallina).[45]

Primary options

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: 5 mg/kg orally every 4-6 hours when required, maximum 40 mg/kg/day; adults: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

Plus – antipruritic agents

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ACUTE
|
all patients
|
with pruritus
Plus – 

antipruritic agents

Treatment recommended for ALL patients in selected patient group

Patients with pruritus associated with miliaria rubra should apply soothing agents such as calamine lotion, menthol, or pramoxine.

When these are not effective, or for more severe cases, a mid-potency corticosteroid such as triamcinolone may be used.[48]

Primary options

calamine lotion topical: children and adults: apply to the affected area(s) when required

OR

menthol/petrolatum topical: children and adults: apply to the affected area(s) when required

OR

pramocaine topical: children >2 years of age and adults: (1%) apply to the affected area(s) up to four times daily when required

Secondary options

triamcinolone topical: children and adults: (0.1%) apply to affected area(s) twice daily

Consider – isotretinoin

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ACUTE
|
all patients
|
with miliaria profunda
Consider – 

isotretinoin

Additional treatment recommended for SOME patients in selected patient group

Although isotretinoin use has been associated with the formation of miliaria crystallina, a short course can be effective in the treatment of miliaria.[4][23][43]

Anecdotal evidence suggests that treatment of miliaria profunda with isotretinoin induced improvement; however, this is not conclusive as treatment was administered concomitantly with topical anhydrous lanolin.[4]

Due to teratogenicity women must undergo pregnancy testing before starting the medicine and monthly while the medicine is being taken.

Prescribing restrictions vary globally; for example, in the US, isotretinoin can only be prescribed under the iPledge system, whereas in the UK, it is prescribed only under consultant supervision; local guidelines should always be followed. iPledge system for prescribing isotretinoin Opens in new window

FBC, lipid panel, and liver function tests are monitored regularly in all patients taking isotretinoin. Women who can potentially fall pregnant also require monthly pregnancy tests.

Primary options

isotretinoin: adults: 0.5 mg/kg/day orally for 2 months

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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