VOL.4 NO.2

Short Review


Prepucial Epstein Pearls: Revisited

M M A Faridi, Arushi Kumar*

Principal, Dean & CMS Department of Pediatrics, Department of Dermatology and Venereology*

Era's Lucknow Medical College & Hospital, Sarfarazganj, Hardoi Road, Lucknow, U. P., India-226003


Milia are minute follicular epidermal cysts, commonly found over the cheeks, nose, upper lip, forehead, and rarely over the areolae and genitalia.Prepucial milia (Prepucial Epstein pearl), are pearly white papules, 1-2mm in size found on the prepuce or shaft of the penis in a male new born. They are benign in nature and almost always disappear within a few weeks. Prepucial milia evoke a lot of concern and anxiety to the parents. Physician and child healthcare providers should be aware of this condition to avoid unnecessary intervention.

Received on : 18-12-2017

Accepted on : 27-12-2017

Address for correspondence

Dr. M M A Faridi

Principal’s Residence

Department of Pediatrics

Eras Lucknow Medical College & Hospital,

Sarfarajganj, Lucknow, U.P., India-226003


Contact no: +91- 9868399740

KEY WORDS: Prepucial milia, Epstein pearls, Prepucial Epstein pearls


In the neonatal period a number of physiological changes can be appreciated on the skin. Most of these conditions are physiological and transient. Their differentiation from other pathological conditions is critical for the neonatologist/paediatrician and dermatologists for prognosis, and for parents to care and seek appropriate medical advice. One of these conditions is milia.

Milia are minute follicular epidermal cysts noted in about 40% newborns (1). They are commonly found over the cheeks, nose, upper lip, forehead, and rarely over the areolae, limbs and genitalia (2). Milia, when present over the palate and alveolar ridges are called Epstein's pearls and Bohn's nodules respectively (1). Single large milia is often described as pearl (2). Presence of milia on the prepuce has been reported as Prepucial Epstein pearl by many authors. Two prospective studies have reported that prepucial Epstein pearls are found in 7.3% to 18.2% male newborn infants though western literature claims it be more common (3-5). Prepucial milia are pearly white to yellow papules, 1-2mm in size found on the prepuce or on the median raphe of the shaft of the penis. They are most commonly found on the tip of the fore-skin at 6o'clock position but may be present few millimetres proximal to the fore skin.

Prepucial milia presents as a single white pearly papule though one case with two prepucial milia, 3

mmapart, has also been reported (6).They are formed due to plugging of the pilosebaceous or eccrine ducts and contain keratin like substance unlike smegma pearls that consists of smegma (7).

They are benign in nature and almost always exfoliate

and disappear on their own within a week, or may persist up to 3 weeks, without leaving any scar or pigmentation. Persistence of milia at unusual sites or widespread distribution may be seen in oro-facial- digital syndrome, hereditary trichodysplasia, p a c h y o n y c h i a c o n g e n i t a a n d d y s t r o p h i c epidermolysis bullosa (8). In few case reports on Prepucial Epstein pearls the infants were healthy on clinical examination; long term follow up was not available.

Close differentials of prepucial milia include smegma pearl, prepucial cyst and prepucial median raphe cysts. They are easily differentiated clinically. Smegma pearls presents as a painless single or multiple whitish- yellow pearly nodule over the glans in uncircumcised boys due to collection of smegma between the base of the glans and the attachment of the prepucial membrane with the glans. They resolve spontaneously

(9). Prepucial cyst is a nodular swelling below the skin of glans due to collection of dead skin and requires no active intervention (7). Median raphe cyst are midline- developmental abnormality that occur as a solitary freely movable nodule on the ventral surface of the penis (10-11). A similar sounding condition is pearly penile papule that develop after puberty and present with one or two rows of skin coloured papules on the corona of glans (12).

Prepucial milia evoke a lot of concern and anxiety to the parents (6). This can lead to unnecessary mental agony especially to the mother which may affect the maternal hormones like oxytocin resulting in failure to breastfeed if not counselled properly. Physician and child health care providers who are not aware of this benign condition may over treat it with unnecessary


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Prepucial Epstein Pearls: Revisited

investigations, puncturing, and antibiotics etc. Prepucial milia is a self resolving physiological condition requiring no intervention. But timely identification and counselling of the parents explaining the benign nature of this condition are imperative for management.

Figure 1 with permission of the authors. [6] Single

prepucial epstein pearl.

Figure 2 with permission of the authors. [6] Two

Prepucial Epstein pearls.


1.Dhar S, Raychaudhury T, Banerjee R, Malakar R. Neonatal skin disorder. In: Sacchidanand S,

Oberai C, Inamadar AC, Editors. IADVL Textbook of Dermatology, 4th ed. Mumbai:

Bhalani Publishing house, 2015. p267.

2.Paige DG. Dermatoses of the Neonate. In: Griffiths C, Barker J, Bleiker T, Chalmers R,

Creamer D, Editors. Rook's Textbook of Dermatology, 9th ed. Oxford: Wiley Blackwell

publishing; 2016. p.116.3-4.

3.Faridi MMA, Adhami S. Prepucial Epstein pearls. Indian J Pediatr. 1989; 56(5):653-5.

4.Singh, J, Gupta, SN. Relationship between prepucial Epstein pearl with gestational age, birth weight and birth order. Indian Pediatr 1994; 31: 582–4

5.Milner RDG, Herber SM. A color atlas of the newborn. Wolfe Medical Publication Ltd, London 1984; Fig 209, p81.

6.Faridi MMA, Sharma A. Managing pearly prepuce-Active communication and masterly inaction. Indian Journal of Child Health. 2017 Nov 14;4(1):107-9.

7.Sonthalia S, Singal A. Smegma pearls in young uncircumcised boys. Pediatric dermatology. 2016 May 1;33(3).

8.Mancini AJ, Paller AS. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. Elsevier Saunders; 2006.p16

9.Sonthalia S, Jha AK. Smegma pearl. Indian

d e r m a t o l o g y o n l i n e j o u r n a l . 2 0 1 7 Nov;8(6):520.

10.Amaranathan A, Sinhasan SP, Dasiah SD. Median raphe cysts of the prepucial skin, with triple histological linings: a case report and review of literature. J ClinDiagn Res 2013;7:1466-1468

11.Cardoso R, Freitas JD, Reis JP, Tellechea Ó. Median raphe cyst of the penis. Dermatology online journal. 2005 Jan 1;11(3).

12.Körber A, Dissemond J. Pearly penile papules. Canadian Med Association J. 2009 Sep 15;181(6-7):397-.

How to cite this article : Faridi MMA., Kumar A., Prepucial Epstein Pearls: Revisited. EJMR2017;4(2):163-164.


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