What to Do About Milia Under the Eyes

Small, benign cysts known as milia—often mistakenly referred to as “fat granules” under the eyes—are a common cosmetic concern. These tiny, white or yellowish bumps form when keratin becomes trapped beneath the surface of the skin, typically around the delicate periorbital area. Importantly, milia are not composed of fat and are unrelated to sebaceous glands or lipid accumulation; they result from abnormal epidermal keratinization.

Unlike acne or sebaceous cysts, milia do not resolve spontaneously in most adults and generally require clinical intervention for removal. Conservative measures such as topical retinoids may help prevent new lesions but are ineffective for existing ones. Manual extraction by a board-certified dermatologist or ophthalmic plastic surgeon remains the gold standard: using a sterile 26- or 27-gauge needle to create a microscopic incision followed by gentle expression with a comedone extractor ensures complete cyst evacuation while minimizing trauma to the thin periocular skin.

Laser ablation—particularly with erbium:YAG or pulsed dye lasers—and radiofrequency micro-needling are emerging alternatives for recurrent or multiple lesions, offering precision and reduced risk of scarring. However, these modalities require specialized training and should be performed only in accredited medical settings. Over-the-counter “milium removal tools” or aggressive scrubbing are strongly discouraged, as they can induce post-inflammatory hyperpigmentation, scarring, or iatrogenic injury to the lower eyelid structures.

Patients presenting with persistent or atypical periorbital papules should undergo evaluation to rule out mimickers—including syringomas, xanthelasma, or basal cell carcinoma—especially if lesions are asymmetric, ulcerated, or rapidly enlarging. A thorough clinical assessment, and occasionally dermoscopy or biopsy, is essential for accurate diagnosis and appropriate management.