What is the treatment for sebaceous cysts?

Treatment for Sebaceous Cysts

Primary Treatment Approach

The definitive treatment for sebaceous cysts (more accurately termed epidermoid cysts) is complete surgical excision of both the cyst contents and the entire cyst wall to prevent recurrence. 1

Understanding the Pathophysiology

• Epidermoid cysts (commonly mislabeled "sebaceous cysts") contain normal skin flora within the keratinous material even when uninflamed 1
• Inflammation and purulence occur as a reaction to rupture of the cyst wall and extrusion of contents into the dermis, rather than as a true infectious complication 1
• This understanding is critical because it guides treatment decisions—the inflammation is often sterile and reactive, not primarily infectious 1

Treatment Algorithm Based on Clinical Presentation

For Uninflamed/Uninfected Cysts

Surgical excision is the gold standard:

• Traditional wide excision removes the entire cyst with surrounding tissue but results in larger scars 2
• Minimal excision techniques offer superior cosmetic outcomes while maintaining complete cyst removal 2, 3

Modern minimally invasive approaches include:

• CO2 laser punch-assisted technique: Create a small hole with CO2 laser, evacuate contents, then remove the cyst wall through the minimal opening—this achieves 0% recurrence in uninfected cysts with mean operative time of 13 minutes 3
• Two-stage laser procedure: First use laser to create small hole for content removal, then perform minimal excision of cyst wall approximately 1 month later—particularly useful for large cysts or those in cosmetically sensitive areas 2
• Intraoral approach: For cysts located in the lip or cheek near the commissure, excision through an intraoral incision avoids visible facial scarring entirely 4

For Inflamed/Infected Cysts

The treatment differs significantly from traditional teaching:

• Incision and drainage alone is inadequate as it does not remove the cyst wall and leads to recurrence 1
• Primary excision with closure is now preferred: Under local or general anesthesia, excise the infected tissue along with a rim of healthy tissue and close primarily with sutures in the same sitting 5
• Sutures are typically removed on day 21 for back lesions and day 14 for limb lesions 5
• This approach provides quicker recovery, eliminates need for frequent dressing changes, and is more cost-effective than traditional incision and drainage 5

Key distinction: Gram stain, culture, and systemic antibiotics are rarely necessary unless there is extensive surrounding cellulitis, multiple lesions, severe systemic symptoms (high fever), or severely impaired host defenses 1

Special Anatomic Considerations

Multiple Scrotal Cysts

• When multiple cysts cover extensive scrotal skin, complete excision of all cysts may be necessary 6
• In cases of severe infection or extensive involvement, the entire scrotal wall may require removal with testicular coverage 6

Facial/Cosmetically Sensitive Areas

• Prioritize minimally invasive techniques (CO2 laser-assisted, two-stage procedures) to minimize scarring 2, 3
• Consider intraoral approach for perioral locations 4

Critical Pitfalls to Avoid

1. Incomplete cyst wall removal: This is the primary cause of recurrence—the entire epithelial lining must be excised 1, 3
2. Overuse of antibiotics: Most inflamed cysts represent sterile inflammation from wall rupture, not bacterial infection requiring antibiotics 1
3. Simple incision and drainage: This outdated approach fails to address the cyst wall and virtually guarantees recurrence 1, 5
4. Delaying definitive treatment: Infected cysts can now be definitively treated with primary excision and closure rather than staged procedures 5

Recurrence Rates by Technique

• CO2 laser-assisted excision: 0% for uninfected cysts, 16.7% for infected cysts 3
• Primary excision with closure of infected cysts: No recurrence reported in case series 5
• Traditional incision and drainage: High recurrence (specific rates not provided but clinically well-established) 1

Postoperative Management

• Simply covering the surgical site with a dry dressing is usually the most effective wound treatment 1
• Some clinicians pack the cavity with gauze or suture it closed, though this is not universally necessary 1
• For infected cyst excisions, avoid frequent dressing changes which increase cross-infection risk 5