What is the recommended treatment for an epidermoid cyst on the scrotum?

From the Guidelines

The recommended treatment for an epidermoid cyst on the scrotum is typically surgical excision, specifically incision and drainage, if the cyst is causing discomfort, growing in size, or becomes infected, as supported by the most recent guidelines 1.

Key Considerations

• For asymptomatic small cysts, observation may be appropriate as many remain stable without intervention.
• When surgical removal is necessary, it's usually performed under local anesthesia as an outpatient procedure.
• The surgeon will make a small incision, carefully remove the entire cyst including its wall to prevent recurrence, and close the wound with absorbable sutures.
• Following surgery, patients should keep the area clean and dry, apply antibiotic ointment like bacitracin or mupirocin twice daily for 5-7 days, and take acetaminophen or ibuprofen as needed for pain.
• Warm compresses can help with discomfort.
• If the cyst becomes infected before surgery, a course of oral antibiotics such as cephalexin 500mg four times daily for 7-10 days may be prescribed to resolve the infection before proceeding with removal, although this decision should be based on the presence of systemic inflammatory response syndrome (SIRS) 1.

Rationale

• Surgical excision is preferred over simple drainage because drainage alone typically leads to recurrence, as the cyst wall remains intact and can refill with keratin debris over time.
• Gram stain and culture of pus from inflamed epidermoid cysts are not recommended 1, unless there are unusual exceptions such as multiple lesions, cutaneous gangrene, severely impaired host defenses, extensive surrounding cellulitis, or severe systemic manifestations of infection 1.
• The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based on the presence or absence of SIRS 1.

From the Research

Treatment Options for Epidermoid Cyst on the Scrotum

• The recommended treatment for an epidermoid cyst on the scrotum is surgical excision 2, 3.
• A minimal excision technique can be used, which involves making a small incision and extracting the cyst wall through the incision 2.
• This technique is less invasive than complete surgical excision and does not require suture closure 2.
• Inflamed cysts are difficult to excise, and it is often preferable to postpone excision until inflammation has subsided 2.
• Histologic evaluation is necessary only if unusual findings or clinical suspicion of cancer is present 2.

Alternative Treatment Approaches

• Percutaneous sclerotherapy has been used as a therapeutic alternative to surgery in the management of epididymal cysts, with a technical success of 100% and no complications 4.
• Delayed primary closure is a new surgical approach for treating infected epidermoid cysts, which involves incising and draining the lesion, followed by removal of the cyst wall and closure of the wound 5.

Rare Cases and Considerations

• Epidermoid cysts of the scrotum extending into the true pelvis are rare and may represent a monodermal teratoma or abnormal closure of the median raphe 6.
• In such cases, surgical exploration and removal of the mass may be necessary, and pathologic examination can confirm the diagnosis of an epidermoid cyst 6.