What is the treatment for epidermoid cysts?

Treatment for Epidermoid Cysts

Complete surgical excision of both the cyst contents and the entire cyst wall is the definitive treatment for epidermoid cysts to prevent recurrence. 1

Primary Treatment Approach

Surgical excision with complete removal of the cyst wall is mandatory because incomplete wall removal is the primary cause of recurrence. 1 The entire epithelial lining must be excised to achieve cure. 1

• Wide local excision is the treatment of choice for epidermoid cysts, particularly when infected, to prevent complications and recurrence. 2
• Most cases can be performed under local anesthesia with a low complication rate of approximately 2.2%. 3
• The surgical site should be covered with a dry dressing postoperatively, which 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

Treatment Algorithm Based on Clinical Presentation

For Uninflamed/Non-infected Cysts

• Proceed directly to complete surgical excision with removal of the entire cyst wall. 1, 2
• Marker sutures should be used during excision to properly orient the specimen for histopathological evaluation. 2
• For facial lesions, careful surgical technique is essential to minimize scarring while ensuring complete removal. 2

For Inflamed/Infected Cysts

Incision and drainage alone is inadequate and leads to recurrence because it does not remove the cyst wall. 1 This is an outdated approach that virtually guarantees recurrence. 1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
• Gram stain, culture, and systemic antibiotics are rarely necessary unless there is extensive surrounding cellulitis, multiple lesions, severe systemic symptoms, or severely impaired host defenses. 1
• Most inflamed cysts represent sterile inflammation from wall rupture, not bacterial infection requiring antibiotics. 1

Alternative Approach for Infected Cysts

• A delayed primary closure technique can be employed: incise and drain on day 1, then 5-7 days later excise the cyst wall parallel to Langer's tension lines and close by delayed primary closure. 4
• Minimally invasive CO2 laser incision (2-3 mm hole, 5W power) combined with photodynamic therapy (PDT) has shown a 97% success rate with excellent cosmetic outcomes, though this is based on limited research evidence. 5

Histopathological Evaluation

Histopathological examination is medically necessary to determine whether lateral and deep margins are clear of any pathology and to assess for any atypical features that might require additional treatment. 2

• Epidermoid cysts contain normal skin flora within the keratinous material even when uninflamed, which is a key factor in understanding their pathophysiology. 1
• Diagnosis requires histopathological confirmation to rule out malignant transformation potential. 3

Critical Pitfalls to Avoid

• Incomplete cyst wall removal is the primary cause of recurrence—the entire epithelial lining must be excised. 1
• Overuse of antibiotics is common but inappropriate, as most inflamed cysts represent sterile inflammation from wall rupture, not bacterial infection. 1
• Simple incision and drainage is an outdated approach that fails to address the cyst wall and has a high recurrence rate. 1
• Treating multiple infected facial cysts as merely cosmetic can lead to progression of infection and worse outcomes. 2

Special Considerations

• Progressive increase in size over 3 months indicates active pathology requiring medical intervention rather than cosmetic treatment. 2
• Ultrasound confirmation of infected cystic lesions provides objective evidence of medical necessity. 2
• Rare genetic disorders with multiple cysts include Gardner and Lowe syndrome. 3