What is the recommended treatment for sebaceous cysts?

Management of Sebaceous Cysts

For sebaceous cysts, complete surgical excision with removal of the entire cyst wall is the recommended treatment for non-inflamed cysts, while incision and drainage is the cornerstone of treatment for inflamed cysts. 1

Treatment Approach Based on Cyst Status

Non-Inflamed Sebaceous Cysts

• Complete surgical excision is the gold standard treatment
  • Requires removal of the entire cyst wall to prevent recurrence
  • Minimum 4-mm margin around the cyst border is recommended 1
  • Results in recurrence rates of only 2.2-8.3% 1
  • Should be performed when the cyst is not actively infected

Inflamed/Infected Sebaceous Cysts

• Incision and drainage (I&D) is the first-line treatment 1
  • Make a small incision over the cyst
  • Thoroughly evacuate the contents
  • Break up any loculations within the cavity
  • Cover with a dry dressing
• Complete excision should be delayed until the acute infection resolves 1
• Consider definitive surgical excision 1-2 months after the infection has completely resolved to prevent recurrence 2

Antibiotic Use

• For small cysts (<5 cm of erythema/induration) with minimal systemic signs of infection, antibiotics are unnecessary 1
• Consider antibiotics only in specific situations:
  • Temperature >38.5°C or heart rate >110 beats/minute
  • Erythema extending >5 cm beyond wound margins
  • Presence of systemic inflammatory response syndrome (SIRS)
  • Markedly impaired host defenses
  • Extensive surrounding cellulitis
  • Failed initial treatment 1

Post-Procedure Care

• Keep the wound clean and dry
• Monitor for signs of infection
• Schedule follow-up to assess wound healing within 7-14 days 1
• For I&D procedures, continue dressing changes until the wound heals by secondary intention

Alternative Techniques

• CO2 laser punch-assisted surgery is a newer, minimally invasive option:
  • Creates a small hole to remove cyst contents
  • Followed by removal of the cyst wall
  • Associated with minimal scarring and high patient satisfaction
  • Shows acceptable recurrence rates (6.0% overall, 0% for uninfected cysts) 3
  • Mean operation time of approximately 13 minutes 3

When to Consider Pathological Examination

• Submit excised tissue for pathological examination if the cyst:
  • Is larger than 1.5 cm
  • Shows rapid growth
  • Presents as a nodular mass
  • Has ulceration or extensive scarring
  • Is fixed to surrounding tissues 1

Treatment Algorithm

1. Assess cyst status: Inflamed/infected vs. non-inflamed
2. For non-inflamed cysts: Proceed with complete surgical excision
3. For inflamed/infected cysts:
   • Perform incision and drainage
   • Consider antibiotics only if meeting specific criteria
   • Schedule follow-up for definitive excision after inflammation resolves (1-2 months)
4. For cosmetically sensitive areas: Consider minimally invasive techniques like CO2 laser-assisted removal 3, 4

Cautions and Pitfalls

• Incomplete removal of the cyst wall is the main cause of recurrence 1
• Attempting complete excision during active infection may lead to complications and higher recurrence rates
• One-stage excision of inflamed sebaceous cysts may be considered in select cases but requires appropriate patient selection and antibiotic coverage 2

Remember that the goal of treatment is complete removal of the cyst to prevent recurrence while minimizing scarring and complications.