Care of patients with miliaria profunda: patient education

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Care of patients with miliaria
profunda: patient education
and management
Mabel Qi He Leow, Wei-Sheng Chong
Miliaria profunda, or sweat rash, is a skin condition that is characterised by the occlusion of the eccrine
sweat duct, resulting in the retention of sweat within the skin. It has a high prevalence in hot, humid
climates and may affect first-time visitors to such climates, including young people on their gap year.
This article will present the pathophysiology of miliaria profunda, methods of diagnosing miliaria
profunda (focusing on the use of thermoregulatory sweat test Sato’s method), patient education on the
preparation for the thermoregulatory sweat test and management of patients with miliaria profunda. It
will include a case of a young male patient diagnosed with miliaria profunda.
KEY WORDS
Education
Miliaria profunda
Thermoregulatory sweat test
Types of miliaria
Miliaria is a skin condition that is
characterised by the occlusion of the eccrine
sweat duct, resulting in the retention of
sweat within the skin (Feldman et al, 2014). It
can be caused by bacterium staphylococcus
producing sticky substances and occluding
the sweat ducts, or intense sweating resulting
in maceration in the stratum corneum, and
keratin plugs that obstruct the eccrine sweat
glands. According to the level of blockage in
sweat ducts, miliaria can be categorised into
various subtypes such as miliaria crystalline,
miliaria rubra and miliaria profunda (Table 1).
Miliaria crystalline is the asymtomatic form.
Miliaria rubra is the common symptomatic
form, characterised by the appearance of
tiny red non-follicular papules.
Miliaria profunda is the most severe
form of miliaria, caused by the blockage
of eccrine ducts at the dermis level (Kirk
et al, 1996). It could occur after several
Mabel Qi He Leow is a Research Nurse and
Wei-Sheng Chong is a Senior Consultant
Dermatologist at National Skin Centre Singapore
32
episodes of miliaria rubra, which is the
occlusion of the eccrine ducts in the
epidermis level (Feldman et al, 2014).
The clinical signs and symptoms of a
patient with miliaria profunda include:
Presence of flesh/whitish coloured
rashes after being in hot sun, which
goes away in less than 1 hour after
cooling down
No sweat production
Rashes are not itchy
Rashes are accompanied with
symptoms such as salivation, shortness
of breath, palpitations, lethargy, and
inability to pass urine
Miliaria profunda usually occurs after
several days to weeks of profuse sweating
(Dobson, Lobitz, 1957). Hence, it is most
common during the summer months
and in those living in tropical countries.
Also, people who are frequently involved
in strenuous activities may also be more
suseptible due to more frequent sweating.
Prevalence of miliaria profunda
Miliaria profunda is a rare and severe form
of miliaria.The prevalence of miliaria is high
in hot and humid countries, for example in
Eygpt miliaria was reported to be the main
Table 1.
Types of
miliaria
Prevalence and incidence
Course of disease
Complications
Miliaria
crystalline
Most common in tropical
Mildest and most superficial form
climates, often occurs in
of miliaria. Asymptomatic and self
neonates and those who move/ limiting — resolves after a few days
travel to hot humid climates
None
Miliaria
rubra
Most common form of miliaria. Pruritus and stinging with associated
Common for all ages in tropical anhidrosis in affected sites
climates. 30% occurs in people
exposed to hot, humid climates
Generalised anhidrosis can
lead to heat exhaustion and
hyperpyrexia. Secondary
infection (impetigo) can occur
Miliaria
profunda
Rarer condition, occurring
in individuals with repeated
miliaria rubra
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Episodes of near fainting when in the sun.
Lesions tend to be asymptomatic.
A complication to miliaria
Main symptom is widespread
rubra. Heat exhaustion in
inability to sweat, due to eccrine duct tropical climates
rupture (tropical anhidrotic asthenia)
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Clinical review
sweat gland disorder with a prevalence rate
of 5.84% (Abdel-Aty et al, 2003). However,
a study of 113 patients experiencing heat
rash in Iraq did not include any diagnosed
miliaria profunda (Al-Hilo et al, 2012).
Susceptibility to miliaria
Studies have reported higher incidence
of miliaria during the summer months
(Abdel-Aty et al, 2003; Al-Hilo et al, 2012).
Miliaria was also found to largely affect
children below the age of 12, with a
prevalence of 9.8% (Abdel-Aty et al, 2003;
Odueko et al, 2001).
Moosavi and Hosseini (2006) have
reported that miliaria affects both sexes
equally. However, Al-Hilo et al (2012)
reported higher incidences of miliaria in
males compared to females, which could
be attributed to the higher exposure of
males to outdoor activities in the sun.
Methods of diagnosing miliaria profunda
(focusing on the use of thermoregulatory
sweat test Sato’s method)
Clinical examination and skin biopsy have
traditionally been used to diagnose miliaria
profunda (Bruckbauer, Vogt, 2003; Kirk et
al, 1996). However, skin biopsy is invasive
and there is potential risk of infection
and scarring. Hence the authors would
recommend use of the thermoregulatory
sweat test (Sato’s method) to diagnose
miliaria profunda.
Thermoregulatory sweat testing
(Sato’s method), also known as a ‘sweat
test’, was originally devised in 1984 for
diagnosis of cystic fibrosis (Sato, Sato,
1984). It has been used to diagnose
autonomic and sudomotor dysfunction
(Illigens, Gibbons, 2011) and disorders in
the eccrine sweat glands. This is done by
inducing maximum sweating during the
test, and using iodine starch to assess the
amount of sweat produced (Hsieh et al,
2001). If little or no sweat is produced
during the test, miliaria profunda is a highly
possible diagnosis. Further, the clinical signs
of miliaria profunda could be observed
during the test.
Sato’s method is used to assess the
amount of sweat and its benefits include:
1 a simple and one-step procedure
2 sensitive visualisation of moderately high
resolution
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26-30_Miliaria.mjjp3C[1].indd 27
3 a non-toxic, non-irritating, non-allergenic
reagent for visualisation
4 inexpensive
5 visualisation of sweat could be performed
on any parts of the body or on the
entire body surface
6 repeated (consecutive) testing would be
possible on the same skin sites
7 the reagent applied to the skin would be
easily removable by wiping the skin with
no residual staining
8 easy removal of stains from towels and
linens (Sato et al, 1988, p1).
Patient education on the preparation for
thermoregulatory sweat test
Prior to the sweat test day
Patient consent must be obtained prior
to the sweat test. The patient will be
briefed on the preparation for the sweat
day. On the day of the sweat test, the
patient will be expected to be dressed
in sports attire (T-shirt and shorts). They
may also like to bring their own toiletries
such as soap and towel as they will need
to bathe after the test.
On the sweat test day
A patient procedural chart will be
documented. The room temperature and
humidity will be recorded. The patient’s
height and weight, and baseline blood
pressure, pulse, and temperature will
be obtained. The patient’s maximum
heart rate based on his/her age will be
calculated to ensure that the patient’s
heart rate will not be exceeded during the
test procedure.
Management of patients with miliaria
profunda
Patient education includes advising
patients to avoid exposure to conditions
of high heat and humidity. Cessation of
exercise is necessary to prevent the rash
and symptoms. If exposed to heat, the
patient can immediately take a cold bath
and the rashes will subside.The patient
may gradually be exposed to heat and
slowly increase physical activity when the
condition improves.
A low dose of isotretinoin (0.5mg/kg/
day) is the main medical treatment given
to unplug the sweat glands. Antibiotics
could be prescribed if bacterial infection is
suspected.
Prevention of milaria profunda
The case study (see box) discusses an Asian
male living in Singapore, which has a humid
climate, who has to frequently exercise in
the sun. Miliaria profunda is a less common
and more severe subtype of miliaria, which
usually occurs due to repeated occurrence
of miliaria rubra.Typically, miliaria profunda
has a rapid onset of between two days and
10 days after exposure to hot conditions
(Al-Hilo et al, 2012).The rashes can appear
within minutes after exposure to the hot
condition, and resolves spontaneously after
the patient is removed from the hot and
humid environment and cools down with a
cold bath.
During the sweat test procedure, the
patient will be required to cycle vigorously
on the bicycle for 20 minutes. A ring pulse
oximeter can be placed on the patient’s
finger to enable convenient reading of pulse
rate.The pulse and temperature should be
obtained every five minutes.
Miliaria can occur in up to three
in 10 people who travel to a hot or
tropical climate on holiday, and sweat
more profusely. An erythematous, pruritic
eruption may begin within a few days of
arrival in the new climatic environment
or it can develop weeks, or even months,
later. Miliaria can also occur in cooler
climates when sweating is a problem
(patient.co.uk).
After this procedure, the iodine
starch spray is administered.The patient
is requested to remove his/her clothes,
except for underwear (to date, no female
patient has performed the sweat test).The
nurse performing the spray must don the
full personal protective equipment (PPE)
and an N95 mask to avoid inhalation of
the iodine starch. Milaria is a highly possible
diagnosis if the test shows that little or no
sweat has been produced.
Health education regarding miliaria
is important for anyone travelling to
countries with hot and humid climates,
or during the summer period. As the
incidence of miliaria is high, travel clinics
and practice nurses should incorporate
information on miliaria into general travel
advice. Travellers could be advised to keep
themselves cool by avoiding direct sunlight
and to take cool baths. They could wear
loose cotton clothing or clothing that has
Dermatological Nursing, 2015, Vol 14, No 1
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Clinical review
Case report
A
24-year-old Chinese Asian male
complained of rashes (flesh-coloured)
after physical activities in hot sun or
humidity for 3 months. He was serving the
mandatory national service in Singapore. Prior
to enlistment he was able to sweat normally.
However, he had noted a reduction in sweating
during the last 3 months.
Initially, after physical activities, the rash only
appeared on the neck. However, it later started
to appear on the face and rest of the body.
The rashes were non-pruritic, had a ‘numb’
sensation, but went away after an hour of
cooling down.The rashes were accompanied
by salivation, shortness of breath (SOB),
palpitations, lethargy, and inability to pass urine.
There were also episodes of near fainting.
During clinical examination at the clinic
no active lesions or rash were observed.The
thermoregulatory sweat test (Sato’s method)
was conducted. After 15 minutes of cycling on
breathable fabric to prevent trapping of
heat. Frequent cold baths and applying
emollient creams kept in a fridge to cool
and soothe the skin can be encouraged.
When signs of miliaria are detected, such
as the appearance of tiny, red, non-follicular
rashes, the person should seek treatment
immediately as prolonged non-treatment
could lead to a more severe state of the
condition, such as miliaria profunda.
References
Abdel-Hafez K, Abdel-Aty MA, Hofny ERM
(2003) Prevalence of skin diseases in rural areas
of Assiut Governorate, Upper Egypt. Int J Derm
42(11): 887-892.
Al-Hilo MM, Al-Saedy SJ, Alwan AI (2012)
Atypical presentation of miliaria in Iraqi
patients attending Al-Kindy teaching hospital in
Baghdad: A clinical descriptive study. Am J Derm
Venereology 1(3): 41-46
Bruckbauer HR, Vogt HJ (2003) Eccrine
miliaria. In: AD Katsambas, TM Lotti (Eds),
European Handbook of Dermatological Treatments
(2nd ed) (pp.145-146). Springer-Verlag, New
York
Dobso RL, Lobitz WC (1957) Some
histochemical observations on the human
eccrine sweat glands. JAMA Derm 75(5):
653-666
34
Figure 1. Close-up of skin on the upper back of
the 24-year-old male. The whitish spots are the
miliaria profunda rashes.
the stationary bicycle, he felt dizzy. Innumerable
flesh-coloured, non-follicular papules were
seen on the face and rest of the body, and
local anhidrosis of 40% was noted. Body
temperature rose by 1.6oC.The clinical findings
were consistent with a diagnosis of miliaria
profunda.
BDNG
Corporate Sponsors
Following blood tests (liver function test,
glucose test, and fasting lipid profile), the patient
was prescribed isotretinoin 10mg daily for three
months (patient weighs 58kg). He was advised
to abstain from the sun and engaging in physical
activities, and to remain in a cool environment
(eg, air-conditioned room). Emollient was also
given to help hydrate the skin. DN
Platinum Sponsors
Feldman SR, Sangueza OP, Pichardo-Geisinger
R, et al (2014) Dermatopathology Primer of
Inflammatory Diseases. Taylor & Francis
Group, FL
Hsieh C, McNeeley K, Chelimsky TC (2001)
The clinical thermoregulatory sweat test induces
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227-234
Illigens BMW, Gibbons CH (2009) Sweating test
to evaluate autonomic function. Clin Autonomic
Res 19(2): 79-87
Kirk JF, Wilson BB, Chun W, Cooper PH (1996)
Miliaria profunda. J Am Acad Dermatol 35(5p2):
854-856
Moosavi Z, Hosseini T (2006) One-year survey
of cutaneous lesions in 1000 consecutive Iranian
newborns. Pediatr Dermatol 23(1): 61-63
Odueko OM, Onayemi O, Oyedeji GA (2001)
A prevalence survey of skin diseases in Nigerian
children. Niger J Med: J National Assoc Res
Doctors Nigeria 10(2): 64-67
Patient.co.uk (2014) Prickly heat (miliaria
profunda). Available from: http://www.patient.
co.uk/health/prickly-heatheat-rash-miliaria
[accessed 28.1.2015]
Sato KT, Richardson A, Timm DE, Sato K
(1988) One-step iodine starch method for direct
visualization of sweating. Am J Med Sci 295(6):
528-531
Sato K, Sato F (1984) Defective beta adrenergic
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and in vitro. J Clin Invest 73(6): 1763-71
Dermatological Nursing, 2015, Vol 14, No 1
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