What are the treatment options for a sebaceous cyst?

Treatment of Sebaceous Cysts

For uncomplicated sebaceous cysts, surgical excision with complete removal of the cyst wall is the definitive treatment to prevent recurrence, while infected cysts require incision and drainage as the primary intervention, with antibiotics reserved only for specific systemic indications. 1, 2

Clinical Assessment and Differentiation

Before treatment, distinguish between:

• Uncomplicated cysts: Painless, longstanding nodules with a palpable capsule beneath the skin, often with a visible dark central punctum 1, 2
• Inflamed/infected cysts: Previously asymptomatic cysts that become painful, enlarged, and tender, containing thick white-yellow keratinous debris mixed with pus rather than pure liquid pus 1, 2

The inflammation in sebaceous cysts typically results from rupture of the cyst wall and extrusion of contents into the dermis, not primary bacterial infection. 1, 2

Treatment Algorithm

For Uncomplicated (Non-Inflamed) Cysts

Complete surgical excision with removal of the entire cyst wall is the treatment of choice to prevent recurrence. 2, 3

Surgical technique options:

• Minimal excision technique: Achieves excellent cosmetic results with extremely low recurrence rates (0.66% in one series of 302 patients) 3
• Two-stage laser approach: For large cysts or cosmetically sensitive areas, use laser to create small opening for content removal, followed by minimal excision of cyst wall approximately 1 month later 4
• Conventional wide excision: Remains an option but causes more surgical trauma 3, 4

For Inflamed/Infected Cysts

Incision and drainage is the cornerstone treatment and is absolutely essential—antibiotics alone are insufficient. 1, 2

Procedural steps:

• Perform adequate incision under local or general anesthesia 1, 5
• Thoroughly evacuate all contents and probe the cavity to break up all loculations 1, 2
• Ideally excise the entire cyst wall in the same sitting to prevent recurrence (can be done with primary closure using non-absorbable sutures, removing stitches at 14-21 days depending on location) 1, 5
• Cover with dry dressing 2

Antibiotic Indications

Do NOT routinely prescribe antibiotics after adequate drainage. Antibiotics are unnecessary when all of the following criteria are met: 1

• Erythema extends <5 cm from the lesion
• Temperature <38.5°C
• Heart rate <110 beats/minute
• WBC count <12,000 cells/µL
• No systemic signs of infection

Add systemic antibiotics ONLY when: 1

• Temperature ≥38.5°C or systemic inflammatory response syndrome present
• Heart rate >110 beats/minute
• Erythema extending >5 cm from margins
• Severely immunocompromised host
• Incomplete source control after drainage
• Multiple lesions or extensive surrounding cellulitis

Antibiotic selection for MRSA coverage (when indicated): 1

• Trimethoprim-sulfamethoxazole, clindamycin, or doxycycline
• Duration: 5-10 days based on clinical response

Critical Pitfalls to Avoid

• Failing to perform adequate incision and drainage is the most critical error—antibiotics alone will fail 1
• Do NOT obtain Gram stain and culture from inflamed epidermoid cysts, as they contain normal skin flora and inflammation is not primarily infectious 1
• Incomplete drainage leads to treatment failure; ensure complete evacuation of all purulent material and loculations 1
• Prescribing antibiotics unnecessarily shows no significant benefit when added to adequate drainage in simple cases 1
• Failing to remove the cyst wall leads to recurrence; complete excision is essential for definitive treatment 1, 2, 3

Special Considerations

For recurrent lesions, consider decolonization strategies including intranasal mupirocin and chlorhexidine washes. 1

For multiple giant cysts or unusual presentations (such as covering entire scrotal skin), complete excision of all cysts may be necessary, with histopathological examination to rule out rare malignant transformation in longstanding cases. 6, 7