What treatment should be offered for a 40-year-old with a infected sebaceous cyst on the scrotal wall that has ruptured, with significant induration around the area?

Management of Infected Sebaceous Cyst on Scrotal Wall

The primary treatment for an infected sebaceous cyst on the scrotal wall that has ruptured with significant induration is prompt incision and drainage, followed by appropriate antibiotic therapy if systemic signs of infection are present. 1

Initial Management

• Incision and drainage (I&D) is the cornerstone of treatment for infected sebaceous cysts and should be performed promptly 1, 2
• The procedure should include complete removal of the cyst wall along with a rim of healthy tissue to prevent recurrence 3
• Gram stain and culture of pus from inflamed epidermoid cysts are not recommended as routine practice 1

Antibiotic Therapy

• For a scrotal wall infected sebaceous cyst with significant induration (1 inch in diameter), antibiotics should be added to incision and drainage due to the extent of surrounding inflammation 1, 2
• First-line antibiotic options include:
  • Dicloxacillin or cephalexin (if MRSA is not suspected) 1
  • Doxycycline, clindamycin, or trimethoprim-sulfamethoxazole (if MRSA is suspected) 1
• The recommended duration of antibiotic therapy is 5-7 days 1, 2

Surgical Approach Considerations

• The procedure can be performed under local anesthesia in most cases 3
• After incision and drainage, two approaches can be considered:
  • Traditional approach: Leave the wound open to heal by secondary intention with regular dressing changes 1, 4
  • Alternative approach: Primary closure with non-absorbable sutures (e.g., Prolene) after thorough debridement of infected tissue 3
• The choice depends on the extent of infection and surrounding cellulitis 3, 4

Monitoring and Follow-up

• Monitor for signs of worsening infection, including fever >38.5°C, tachycardia >110 beats/minute, or extension of erythema beyond 5 cm from the wound margins 5, 2
• Rapid progression of symptoms within hours may indicate Fournier's gangrene, which requires emergency surgical debridement 4
• Follow-up within 48-72 hours to assess response to treatment 2

Special Considerations for Scrotal Location

• Scrotal infections require particular attention due to the risk of rapid progression to Fournier's gangrene 4
• The thin scrotal skin and loose connective tissue can allow infections to spread quickly 4, 6
• Complete removal of the cyst wall is essential to prevent recurrence 3, 6

Pitfalls and Caveats

• Failure to completely remove the cyst wall may lead to recurrence 3
• Inadequate drainage can result in persistent infection despite antibiotic therapy 5, 2
• Clinicians often have higher acceptance rates for recommendations to increase antibiotic exposure than to decrease it, potentially leading to overtreatment 7
• Fournier's gangrene can be masked by infected sebaceous cysts and should be considered if there is rapid progression of symptoms 4