What treatment should be prescribed for a patient presenting with painful sebaceous cysts under the armpit, characterized by severe tenderness and limited arm mobility, without signs of systemic infection?

Management of Painful Sebaceous Cysts Under the Armpit

The primary treatment for painful sebaceous cysts under the armpit is incision and drainage, followed by complete excision once the acute inflammation resolves. 1

Initial Assessment and Management

For Painful, Inflamed Sebaceous Cysts:

1. Incision and drainage is the recommended first-line treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles 1

   • This allows evacuation of the purulent material and relieves pressure
   • Simply covering the surgical site with a dry dressing is usually the most effective post-drainage wound management 1

2. Antibiotic therapy considerations:

   • For axillary region infections, the recommended antibiotics are:
     • Cefoxitin OR
     • Ampicillin-sulbactam 1
   • For uncomplicated cases without systemic symptoms (fever, tachycardia, tachypnea, abnormal WBC), antibiotics may not be necessary 1, 2
   • If antibiotics are indicated due to surrounding cellulitis or systemic symptoms, amoxicillin-clavulanate 875/125 mg PO twice daily is recommended as first-line therapy 2

3. Pain management:

   • Acetaminophen or NSAIDs for pain control 2
   • Warm compresses can help with pain and promote drainage 2

When to Add Antibiotics

Antibiotics should be added when:

1. Systemic inflammatory response syndrome (SIRS) is present:

   • Temperature >38°C or <36°C
   • Tachypnea >24 breaths per minute
   • Tachycardia >90 beats per minute
   • White blood cell count >12,000 or <400 cells/µL 1

2. There is significant surrounding cellulitis or evidence of spreading infection 2

3. The patient has markedly impaired host defenses 1

Follow-up Care

1. Re-evaluation within 48-72 hours to assess healing progress 2

2. Complete excision of the cyst should be considered once the acute inflammation resolves to prevent recurrence 2

3. Investigation for recurrence causes if this is a repeated issue:

   • Search for local causes such as hidradenitis suppurativa or foreign material 1

Special Considerations

Diagnostic Testing:

• Gram stain and culture of pus from inflamed epidermoid cysts are NOT recommended for typical cases 1
• However, if infection is suspected (failure to respond to antibiotics, painful lesions, pustules, yellow crusts, discharge), bacterial culture should be obtained 1

When to Refer:

• Consider dermatology referral for:
  • Multiple or recurrent cysts
  • Unusual appearance or distribution
  • Signs of necrosis, blistering, or atypical manifestations 1

Prevention of Recurrence:

• Good hygiene practices are essential 2
• Avoid frequent washing with hot water 1
• Avoid skin irritants 1
• Consider urea-containing (5%-10%) moisturizers 1

Potential Complications

• Spread of infection to adjacent structures
• Systemic infection
• Recurrence if drainage is inadequate
• Fistula formation 2

While sebaceous cysts are common, their presentation as multiple painful cysts can be challenging to manage. The cornerstone of treatment remains proper drainage with consideration of antibiotics when systemic symptoms or significant surrounding cellulitis are present.