Treatment of Ingrown Hair Cysts
For inflamed ingrown hair cysts (epidermoid cysts), perform incision and thorough evacuation of contents with probing to break up loculations, covered by a dry dressing—systemic antibiotics are rarely necessary unless there is extensive surrounding cellulitis, severe systemic infection, or severely impaired host defenses. 1
Primary Treatment Approach
The cornerstone of management is mechanical drainage rather than antibiotic therapy, as the pathophysiology involves a foreign body inflammatory reaction to keratin and hair rather than a primary infectious process 1, 2:
- Incision and drainage: Make an incision over the cyst and thoroughly evacuate all keratinous contents 1
- Probe the cavity: Break up any loculations within the cyst to ensure complete drainage 1
- Apply dry dressing: Cover the surgical site with a dry dressing after evacuation 1
When Antibiotics Are Indicated
Systemic antibiotics should be reserved for specific complicating factors 1:
- Extensive surrounding cellulitis extending beyond the immediate cyst area 1
- Multiple lesions present simultaneously 1
- Severe systemic manifestations of infection (fever, malaise) 1
- Severely impaired host defenses (immunocompromised patients) 1
- Cutaneous gangrene 1
When antibiotics are prescribed for signs of cellulitis or systemic infection, treat similarly to other cutaneous abscesses 3.
Prevention and Long-Term Management
For patients with recurrent ingrown hairs (pseudofolliculitis barbae), address the underlying cause 2, 4:
- Modify shaving technique: Improper shaving causes ingrown hairs through both transfollicular and extrafollicular mechanisms 2
- Consider alternative hair removal: The curved hair follicles common in certain populations predispose to ingrown hairs 2
- Individualized prevention: Treatment must be tailored as not all regimens work for each patient, but with diligence, pseudofolliculitis can often be controlled 2
Important Clinical Distinction
Recognize that inflammation in epidermoid cysts typically results from rupture of the cyst wall and extrusion of contents into the dermis, not from bacterial infection 1. This explains why mechanical evacuation is more effective than antibiotics alone. The cysts contain normal skin flora even when uninflamed, but this does not represent active infection requiring antimicrobial therapy 1.