Treatment of Sebaceous Cyst with Foul-Smelling Discharge
For a sebaceous cyst with foul-smelling discharge, perform incision and drainage with thorough evacuation of contents, probing to break up loculations, followed by dry dressing—antibiotics are rarely necessary unless there is extensive surrounding cellulitis, systemic signs of infection, or immunocompromise. 1, 2
Understanding the Clinical Presentation
The foul-smelling discharge indicates an inflamed or ruptured cyst rather than a true bacterial infection. 1 The pathophysiology involves:
- Rupture of the cyst wall causing extrusion of keratinous contents into surrounding dermis 1
- Sterile inflammatory reaction to the cyst contents, not primary infection 1
- Normal skin flora present even in uninflamed cysts 1
This distinction is critical because it fundamentally changes the treatment approach.
Immediate Management Algorithm
Step 1: Incision and Drainage
- Make an adequate incision to allow complete evacuation 1, 2
- Thoroughly evacuate all cyst contents including the cheesy keratinous material 1
- Probe the cavity to break up any loculations 1
- Cover with dry dressing 1
Step 2: Determine Need for Antibiotics
Antibiotics are NOT routinely indicated unless the following complicating factors are present: 1, 2
- Multiple lesions
- Cutaneous gangrene
- Severely impaired host defenses (immunocompromise)
- Extensive surrounding cellulitis
- Severe systemic manifestations of infection (fever, sepsis)
Do NOT obtain gram stain or culture of the purulent material—this is explicitly recommended against by the Infectious Diseases Society of America. 2
Definitive Treatment
Complete Excision Timing
- Definitive excision should be performed after acute inflammation resolves to prevent recurrence 2, 3
- One approach involves excision with primary closure in the same sitting even during infection, with excellent results (0.66% recurrence rate) 3, 4
- Alternative: Two-stage approach with laser punch removal of contents followed by minimal excision of cyst wall 1 month later for cosmetically sensitive areas 5
Surgical Technique Considerations
- Complete removal of cyst wall is essential to prevent recurrence 2, 4
- Minimal-incision techniques provide good cosmetic results with low recurrence rates 4
- Sutures typically removed on day 14 for limbs, day 21 for back 3
Critical Pitfalls to Avoid
Do not treat this as a simple abscess requiring antibiotics—the inflammation is typically sterile and antibiotics add no benefit while increasing cost and resistance. 1, 2
Do not perform incomplete drainage—failure to probe and break up loculations leads to persistent inflammation and potential recurrence. 1
Do not leave the cyst wall intact—incomplete excision results in high recurrence rates. 2, 4
Special Circumstances
For cysts in cosmetically sensitive areas (face, visible neck), consider:
- Referral to experienced surgeon for optimal cosmetic outcome 2
- Two-stage laser-assisted technique for large cysts 5
For multiple cysts or unusual presentations (covering large areas), complete surgical removal may be necessary. 6