Treatment of Pilar Cysts
Surgical excision is the definitive treatment for pilar cysts, with complete removal of the cyst wall being essential to prevent recurrence. While asymptomatic cysts can be observed, symptomatic or enlarging pilar cysts should be surgically removed to prevent complications such as inflammation, rupture, or infection.
Clinical Presentation and Diagnosis
- Pilar cysts (trichilemmal cysts) are benign lesions arising from hair follicle epithelium
- Most commonly occur on the scalp but can also appear in other areas of the head and neck
- Typically present as firm, mobile, dome-shaped nodules
- Usually slow-growing and painless unless infected or inflamed
- Occur in approximately 10% of the population, with higher prevalence in women 1
Treatment Options
1. Observation
- Appropriate for asymptomatic, small cysts
- No intervention needed if the cyst is not causing discomfort or cosmetic concerns
- Regular monitoring may be considered for larger cysts
2. Surgical Excision (Primary Treatment)
- Complete surgical excision is the treatment of choice for symptomatic pilar cysts 2, 1
- Ensures removal of the entire cyst wall to prevent recurrence
- Can be performed under local anesthesia in an outpatient setting
- Techniques include:
- Traditional excision with primary closure
- Punch incision technique for smaller cysts (8.3% recurrence rate) 3
3. Management of Complications
- Infected cysts may require:
- Incision and drainage
- Antibiotics if significant surrounding cellulitis
- Delayed complete excision after infection resolves
Surgical Considerations
- Complete removal of the cyst wall is crucial to prevent recurrence
- For scalp cysts, care should be taken to avoid damage to hair follicles
- Histopathological examination of the excised specimen is recommended to rule out malignant transformation (proliferating trichilemmal cyst) 2
Potential Complications
- Recurrence (particularly with incomplete excision)
- Infection
- Scarring
- Rare malignant transformation to proliferating trichilemmal cysts 2
Follow-up
- Suture removal typically 7-14 days post-procedure
- Patients should be educated about signs of recurrence or infection
- No long-term follow-up is necessary for benign, completely excised cysts
Special Considerations
- Multiple or recurrent pilar cysts may require more extensive surgical planning 4
- Pilar cysts in unusual locations may mimic other conditions and require careful diagnostic evaluation 1
- Rare variants with ductal differentiation have been reported but do not alter management 5
Surgical excision remains the gold standard treatment for pilar cysts, offering definitive resolution with a low recurrence rate when performed properly with complete removal of the cyst wall.