Should I refer a patient with a sebaceous cyst on their back to a specialist, such as a dermatologist, or attempt removal in the office?

Management of Sebaceous Cysts on the Back

Most sebaceous cysts on the back can be safely removed in the office setting using minimal excision techniques, which offer excellent cosmetic outcomes and low recurrence rates when the cyst wall is completely removed. 1, 2

Key Clinical Principles

Sebaceous cysts are benign lesions that do not require specialist referral unless complications exist. The decision to treat in-office versus refer depends primarily on:

• Infection status - Uninflamed cysts are ideal for office removal 1
• Size and complexity - Most cysts, including large ones, can be managed in primary care 2, 3
• Your surgical comfort level - The techniques are straightforward with proper training 2

Understanding Cyst Inflammation vs. Infection

Inflammation in sebaceous cysts typically results from cyst wall rupture and extrusion of contents into the dermis, not from primary bacterial infection. 1 Even uninflamed cysts harbor normal skin flora. 1

Systemic antibiotics are rarely necessary unless specific complications exist: 1

• Multiple lesions
• Cutaneous gangrene
• Severely impaired host defenses
• Extensive surrounding cellulitis
• Severe systemic manifestations (high fever)

Gram stain and culture are typically unnecessary. 1

Office-Based Treatment Approach

For Uninflamed Cysts (Preferred Scenario)

The minimal excision technique offers the best balance of complete removal and cosmetic outcome: 2

• Recurrence rate of only 0.66% with minimal-incision techniques in a series of 302 patients over 18 months 2
• Mean operative time of 13 minutes for modern laser-assisted approaches 4
• Zero recurrence in uninfected cysts (0 of 21) using CO2 laser punch-assisted technique 4

Surgical technique: 1, 2

1. Pre-separate the cyst wall by injecting large volume of local anesthetic around the cyst
2. Make a small incision (punch or minimal incision)
3. Thoroughly evacuate all contents
4. Probe the cavity to break up loculations
5. Remove the entire cyst wall - this is critical to prevent recurrence
6. Cover with dry dressing

For Inflamed/Infected Cysts

You can still treat infected cysts in the office, but expect higher recurrence rates: 4

• 16.7% recurrence rate (2 of 12) for infected cysts versus 0% for uninfected 4

Treatment approach for infected cysts: 1, 5

1. Incision and thorough evacuation of contents
2. Probe cavity to break up loculations
3. Dry dressing application
4. Consider excision of infected tissue with rim of healthy tissue and primary closure 5
5. Systemic antibiotics only if complications present (see criteria above) 1

Alternative staged approach for large or cosmetically sensitive cysts: 6

• First stage: Laser punch to drain contents
• Second stage: Minimal excision of cyst wall approximately 1 month later
• This offers complete removal with minimal scarring 6

When to Consider Referral

Referral is rarely necessary but consider it for: 3

• Multiple giant cysts requiring extensive surgery
• Concern for malignant transformation in long-standing cysts
• Cysts in anatomically complex areas where you lack surgical confidence
• Patient preference for specialist care

Critical Pitfall to Avoid

The most common cause of recurrence is incomplete removal of the cyst wall. 1, 2 Simply draining contents without removing the wall leads to recurrence. You must either:

• Remove the entire cyst wall at initial procedure, OR
• Plan a staged approach with definitive wall excision 6