Treatment of Multiple Scrotal Sebaceous Cysts with Pruritus
For 200-300 small scrotal sebaceous cysts causing itchiness, initial management should focus on symptomatic relief with topical hydrocortisone for pruritus, followed by definitive surgical excision only if cysts become infected, significantly symptomatic, or cosmetically unacceptable to the patient.
Immediate Symptomatic Management
Pruritus Control
- Apply topical hydrocortisone to the affected scrotal area 3-4 times daily for itch relief 1
- Clean the area with mild soap and warm water, rinse thoroughly, and gently dry before application 1
- This provides temporary relief of external genital itching associated with minor skin irritations 1
- Hydrocortisone functions as an anti-itch agent for scrotal symptoms 1
Conservative Observation
- Most uncomplicated sebaceous cysts can be observed without intervention 2
- Treatment is only indicated when cysts become infected, cause significant symptoms, or are cosmetically unacceptable 3, 4
- Simple observation is appropriate for asymptomatic cysts 2
Indications for Surgical Intervention
When to Proceed with Excision
- Infection develops (erythema, warmth, tenderness, purulent drainage) 3, 2, 5
- Persistent symptoms despite conservative management 6, 4
- Patient desires removal for cosmetic reasons 6, 4
- Rapid growth or unusual clinical features suggesting possible malignancy 3
Warning Signs Requiring Urgent Evaluation
- Fever, tachycardia, or systemic signs of infection 5
- Extensive surrounding cellulitis 5
- Acute scrotal pain with erythema (to rule out Fournier's gangrene) 7
- Necrosis of scrotal tissue 7
Surgical Management Options
For Infected Cysts
- Incision and drainage is the primary treatment for inflamed epidermoid cysts 3, 2
- Systemic antibiotics are generally unnecessary unless extensive cellulitis, systemic infection signs, multiple lesions, or immunocompromise present 3, 5
- Treat acute inflammation first with warm compresses and possibly antibiotics, then postpone definitive excision until inflammation subsides 3
For Definitive Excision of Multiple Cysts
- Complete excision under local anesthesia with a 2mm rim of normal skin 5
- Elliptical incision with long axis parallel to skin lines for optimal cosmetic results 5
- Use scalpel rather than laser or electrocautery to preserve histological features 5
- For extensive involvement (as in your case with 200-300 cysts), CO2 laser in superpulse mode (10-10.8W, 20ms pulse duration) offers excellent cosmetic results with minimal scarring 8
- One to two 10-minute sessions may be required to treat all cysts 8
For Massive Scrotal Involvement
- If cysts cover the entire scrotal wall, complete scrotal wall resection followed by scrotoplasty may be necessary 6, 4
- Thigh fasciocutaneous flap can be used to cover denuded testes 6
- This approach provides good outcomes with low morbidity and excellent aesthetic results 6
Post-Procedure Management
Wound Care
- Cover surgical site with dry dressing 2, 5
- Some clinicians may pack with gauze depending on wound size 2
- All excised tissue must be sent for histopathological examination 3, 5
Follow-up
- Monitor for signs of infection at surgical site 3
- Watch for recurrence (recurrence rate with proper technique is extremely low at 0.66%) 9
- Educate patient about wound care and complications requiring immediate attention 5
Critical Pitfalls to Avoid
- Do not attempt complete excision of inflamed/infected cysts initially - this is technically difficult and increases complications 3
- Do not miss Fournier's gangrene - multiple infected scrotal cysts can mask this life-threatening condition 7
- Do not use antibiotics routinely for simple uninfected cysts - they are not indicated 2, 5
- Do not ignore rapid growth or unusual features - obtain histopathology to exclude malignancy 3