What is the treatment for a sebaceous cyst on the nipple?

Treatment of Sebaceous Cyst on the Nipple

A sebaceous cyst on the nipple should be managed with incision and drainage if inflamed, or complete surgical excision if non-inflamed, with careful attention to exclude malignancy given the nipple location. 1

Initial Evaluation

The first priority is to distinguish a true sebaceous (epidermoid) cyst from concerning breast pathology, particularly given the nipple location:

• Rule out malignancy first: Any nipple skin changes, including masses or cyst-like lesions, require imaging evaluation to exclude Paget's disease of the breast or other malignancies 1
• Perform bilateral diagnostic mammogram and/or ultrasound based on age (≥40 years: mammogram first; <40 years: ultrasound may suffice) 1, 2
• If imaging shows BI-RADS 1-3 (negative to probably benign) and the lesion appears consistent with a simple cyst, proceed with cyst-specific management 1
• If imaging shows BI-RADS 4-5 or any suspicious features, punch biopsy of the nipple skin is mandatory before treating as a benign cyst 1

Management Based on Clinical Presentation

For Inflamed/Infected Cysts:

• Incision and drainage is the primary treatment 1
• Make an adequate incision, thoroughly evacuate pus, and probe the cavity to break up loculations 1
• Cover with dry dressing (packing or suturing is optional) 1
• Antibiotics are rarely necessary unless extensive surrounding cellulitis, multiple lesions, or systemic symptoms (fever) are present 1
• Gram stain and culture are not routinely needed 1

For Non-Inflamed Cysts:

• Complete surgical excision is the definitive treatment 1, 3
• The cyst wall must be removed entirely to prevent recurrence 1
• For cosmetically sensitive areas like the nipple, consider a two-stage approach: laser punch to drain contents first, followed by minimal excision of the cyst wall approximately 1 month later 3
• This staged technique results in smaller scars compared to conventional wide excision 3, 4

Important Caveats

Pathologic evaluation is only necessary when clinical suspicion exists based on history or physical characteristics suggesting malignancy (incidence of malignancy in presumed sebaceous cysts is 0.3%, most commonly squamous cell carcinoma) 5

Key warning signs requiring biopsy:

• Nipple excoriation, scaling, or eczema-like changes (concern for Paget's disease) 1
• Rapid growth or unusual appearance 5
• Fixed or irregular borders 1
• Any bloody discharge from the lesion 6

Avoid these pitfalls:

• Do not assume all nipple lesions are benign cysts—imaging is mandatory to exclude breast malignancy 1
• Do not simply aspirate epidermoid cysts without removing the cyst wall, as this leads to recurrence 1
• Do not delay evaluation with prolonged antibiotic trials if infection is not clearly present 1