Most likely: milia, with possible closed comedones

• Milia are tiny, firm, pearly-white keratin cysts just under the skin. They commonly occur on the cheeks and around the eyelids.
• Some of the smaller bumps could also be closed comedones (non-inflamed clogged pores), especially if there is acne, oily skin, or use of heavy creams, oils, sunscreen, or makeup.

Other possibilities

1. Closed comedonal acne
   Usually many skin-colored or white bumps, often on cheeks, forehead, chin, or jawline. Can be worsened by comedogenic cosmetics, hair oils, sweating, and hormonal acne.
2. Pityriasis alba
   This causes larger, flat, poorly defined lighter areas with fine dryness or scale, often on the cheeks. It is more noticeable after sun exposure. The image does not strongly suggest it because the visible lesions seem raised. Dermatology 2-Volume Set, p. 1324.
3. Post-inflammatory hypopigmentation
   Lighter marks after acne, eczema, irritation, scratching, or a healing rash. These are usually flat, rather than firm tiny bumps.
4. Tinea versicolor
   A superficial yeast rash with fine scale, usually more prominent on the trunk, neck, shoulders, or upper back. Facial involvement can occur, but the photo is not classic for this. A clinician can check scale or perform a simple KOH scraping if needed.
5. Vitiligo
   Typically flat, clearly defined, completely white patches rather than multiple tiny raised papules. A dermatologist can assess this with a Wood lamp if there is doubt. Andrews' Diseases of the Skin E-Book Clinical Dermatology, p. 1002.

Safe initial management

• Use a gentle, fragrance-free cleanser twice daily.
• Use a light, non-comedogenic moisturizer and sunscreen labeled “non-comedogenic.”
• Avoid heavy facial oils, thick cold creams, greasy makeup, and steroid creams on the face unless prescribed.
• Do not squeeze, scratch, or try to puncture the bumps, especially near the eye. This can cause infection, scarring, or dark marks.
• If these are mainly clogged pores, consider adapalene 0.1% gel at night, a pea-sized amount for the full acne-prone area, starting only 2-3 nights per week. Keep it away from eyelids, corners of the nose, and lips. Stop if significant burning or peeling occurs.
• Do not use adapalene or other retinoids if pregnant, trying to become pregnant, or breastfeeding without clinician advice.
• If they are true milia and persist, a dermatologist can remove them safely by sterile extraction, electrodessication, or other in-office methods. Clinical milia treatment options include observation, retinoids, and professional extraction.

Please arrange a dermatology review if

• The spots spread quickly, itch, scale, become red or painful
• You develop definite flat white patches with sharp borders
• There is hair whitening in the areas
• They persist after 2-3 months of gentle acne-directed care
• You want removal, particularly because several are close to the eye