Approach

As forms of miliaria are due to excessive sweating, often in the setting of a hot/humid environment, the most effective treatment is to regulate the heat and humidity of the patient's environment to reduce sweating.[1] Overall, the only effective treatment and prevention is to avoid further sweating.[7]

Cool environment and supportive care

In the setting of miliaria crystallina, a few hours in a cool environment will often bring quick 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] Cooling fans can be a useful adjunctive measure, especially in patients with fever-induced miliaria crystallina.

A number of treatments have been shown to support relief of symptoms, by preventing either excess sweating or sweat-induced maceration. All patients should be advised to wash regularly to remove salt and bacteria from the skin, particularly when in a hot/humid environment.[4] Cornstarch and other absorbent powders may also be used to absorb sweat and reduce moisture to prevent the formation of miliaria.[38] Moisturising ointments such as anhydrous lanolin may both prevent and treat miliaria by facilitating the normal flow of sweat.[40][41][42][43] Oral ascorbic acid has been reported as effective in the prevention and treatment of miliaria.[44]​ Antipyretics may be used to lower the temperature of febrile patients.[45]

Antibacterial therapy

Because of the possible causative role of Staphylococcus epidermidis in all forms of miliaria, both topical and systemic antibacterials are another consideration especially as prophylaxis.[18][43]​ Both oral and systemic antibacterials have been shown to be effective in preventing experimentally induced miliaria, although their use in the treatment of established miliaria is less clear.[1][18][39][40]​ ​​ Topical treatment, such as chlorhexidine, may be added to a supportive care regimen.

Antipruritics

Pruritus is a common symptom of miliaria, especially miliaria rubra, and should be treated when required. Menthol- and pramoxine-containing lotions both reduce symptoms of pruritus in patients with miliaria by depressing cutaneous sensory receptors.[46][47] Calamine lotion is also effective, probably because it contains zinc oxide, which can have a drying effect. For more severe cases, or where first-line treatments are not effective, a mid-potency topical corticosteroid may be used.[48]

Isotretinoin

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

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