Treatment of Sebaceous Cysts
Complete surgical excision of both the cyst contents and the entire cyst wall is the definitive treatment for sebaceous cysts, as this is the only approach that prevents recurrence. 1
Understanding the Pathophysiology
- Sebaceous cysts (more accurately termed epidermoid cysts) contain normal skin flora within keratinous material even when uninflamed 1
- Inflammation and purulence represent a sterile inflammatory reaction to cyst wall rupture and extrusion of contents into the dermis, rather than true bacterial infection 1
- This pathophysiology explains why antibiotics are rarely necessary and why complete wall removal is essential 1
Treatment Algorithm Based on Clinical Presentation
For Uninflamed/Asymptomatic Cysts
Complete surgical excision under local anesthesia is the standard approach: 2
- Make an elliptical incision with the long axis parallel to skin lines for optimal cosmetic results 2
- Include a narrow rim (2 mm) of normal skin around the cyst 2
- Use a scalpel rather than laser or electrocautery to preserve histological features 2
- Remove the entire cyst wall intact to prevent recurrence 1
Post-operative management:
- Cover the surgical site with a dry dressing, which is usually sufficient 1, 2
- Some clinicians may pack the cavity with gauze or suture it closed, though this is not universally necessary 1
- Send all excised tissue for histopathological examination 2
For Inflamed or Infected Cysts
Most infected sebaceous cysts can be managed in the outpatient setting with complete excision: 2
- Incision and drainage alone is inadequate and leads to recurrence because it fails to remove the cyst wall 1
- Complete excision of the infected tissue along with a rim of healthy tissue can be performed in the same sitting, even when infected 3
- Primary closure with sutures is feasible and provides quick recovery 3
Antibiotics are rarely necessary unless: 1, 2
- Extensive surrounding cellulitis is present
- Multiple lesions with severe systemic symptoms exist
- Severely impaired host defenses are present
- Signs of systemic toxicity (fever, tachycardia, tachypnea, hypotension) are evident
Indications for Hospital Admission
Consider hospitalization only for: 2
- Signs of systemic toxicity (fever, tachycardia, tachypnea, hypotension)
- Extensive surrounding cellulitis indicating spreading infection
- Severely impaired host defenses
- Multiple lesions with severe systemic manifestations
- Suspected necrotizing infection requiring aggressive surgical debridement
Alternative Surgical Approaches
For cysts in cosmetically sensitive areas:
- Cysts located in the lip or cheek near the lip commissure can be excised via an intraoral approach to avoid visible facial scarring 4
- A two-stage laser punch technique can be used for large cysts or those in areas of thick skin: first, create a small hole with laser to remove contents, then perform minimal excision of the cyst wall approximately 1 month later 5
Critical Pitfalls to Avoid
Incomplete cyst wall removal is the primary cause of recurrence: 1
- The entire epithelial lining must be excised
- Simple incision and drainage is an outdated approach that virtually guarantees recurrence
- Traditional incision and drainage has a high recurrence rate
Overuse of antibiotics is common but inappropriate: 1
- Most inflamed cysts represent sterile inflammation from wall rupture, not bacterial infection
- Gram stain, culture, and systemic antibiotics are rarely necessary
Failure to send tissue for histopathology: 2
- All excised tissue must be examined histologically
- Malignant transformation, though rare, has been reported in long-standing cases 6