Treatment Options for Skin Cysts
Surgical excision is the definitive treatment for skin cysts, with incision and drainage being the recommended approach for inflamed or infected cysts. 1
Types of Skin Cysts and Diagnosis
Skin cysts can be classified into several types:
- Epidermoid cysts - Most common type, containing keratin and cellular debris
- Pilar cysts - Typically found on the scalp
- Dermoid cysts - Congenital cysts containing skin appendages
- Sebaceous cysts - Cysts of the sebaceous gland
Diagnostic Features
- Presence of a central punctum (opening) is characteristic of epidermoid cysts 2
- Ultrasound can help differentiate cyst types, with sebaceous cysts typically showing:
- Oval-shaped, hypoechoic appearance
- "Pseudotestis" homogeneous appearance in about 50% of cases
- Visible skin pores on high-frequency ultrasound 3
Treatment Algorithm
1. Non-inflamed, Asymptomatic Cysts
- Option 1: Observation - Appropriate for small, asymptomatic cysts
- Option 2: Complete surgical excision - Recommended to prevent recurrence 2
- Can be performed under local anesthesia
- Complete removal of cyst wall is essential to prevent recurrence
2. Inflamed or Infected Cysts
First-line treatment: Incision and drainage 1
- Recommended for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles
- Simply covering the surgical site with a dry dressing is usually sufficient
- Packing the wound may cause more pain without improving healing
Antibiotic therapy considerations:
- Antibiotics are generally unnecessary unless there are signs of systemic infection
- Consider antibiotics if patient has:
- Systemic inflammatory response syndrome (SIRS)
- 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
Antibiotic selection:
- For MRSA coverage: Consider doxycycline, clindamycin, or SMX-TMP
- For standard coverage: Cephalexin 250-500mg every 6-12 hours 4
3. Recurrent Cysts
- Evaluate for underlying causes such as:
- Pilonidal cyst
- Hidradenitis suppurativa
- Foreign material 1
- Complete surgical excision with removal of entire cyst wall is crucial to prevent recurrence 2
Special Considerations
Multiple Cysts
- Multiple cysts may indicate genetic disorders such as Gardner syndrome or Lowe syndrome 2
- In severe cases with numerous cysts (steatocystoma multiplex), surgical incision, drainage, and electrocautery may be beneficial 5
Digital Myxoid Cysts
- Treatment options include:
- Observation for asymptomatic lesions
- Puncture and drainage
- Sclerotherapy (77% success rate)
- Cryotherapy (72% success rate)
- Corticosteroid injections (61% success rate)
- Surgical excision (95% success rate) 6
Complications and Follow-up
- Complication rate for surgical treatment is low (approximately 2.2%) 2
- Pathological examination of excised cysts is standard practice to:
- Determine the nature of the cyst
- Rule out malignancy
- Document size, wall thickness, contents, and presence of solid areas
Pitfalls to Avoid
- Incomplete removal: Failure to completely remove the cyst wall is the most common cause of recurrence
- Misdiagnosis: Some cysts may mimic other conditions; histopathological confirmation may be necessary
- Unnecessary antibiotics: Routine use of antibiotics is not recommended for uncomplicated cysts after incision and drainage
- Inadequate drainage: For infected cysts, complete evacuation of pus is necessary for larger infected cysts or abscesses