What is the treatment for sebaceous cysts?

Treatment of Sebaceous Cysts

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

Understanding the Pathophysiology

• Sebaceous cysts (more accurately termed epidermoid cysts) contain normal skin flora within keratinous material even when uninflamed, which is critical to understanding treatment decisions 1
• Inflammation and purulence represent a sterile reaction to rupture of the cyst wall and extrusion of contents into the dermis, rather than true bacterial infection 1, 2
• The cyst wall is lined by stratified squamous epithelium and contains keratin debris and cholesterol 3

Primary Treatment Algorithm

For Uninflamed/Asymptomatic Cysts

Elective complete surgical excision with removal of the entire epithelial lining is the treatment of choice. 1

• The entire cyst wall must be excised to prevent recurrence—incomplete wall removal is the primary cause of treatment failure 1
• For large cysts or those in cosmetically sensitive areas, a two-stage approach can be considered: first, laser punch removal of cyst contents, followed by minimal excision of the cyst wall approximately 1 month later 4
• For cysts located in the lip or cheek near the lip commissure, an intraoral approach through the buccinator or orbicularis oris muscle avoids visible facial scarring 5

For Inflamed/Infected Cysts

Incision and drainage with complete cyst wall excision is required, though the wall removal can be performed in the same sitting under appropriate anesthesia. 2

• Incision and drainage alone is inadequate and leads to virtually guaranteed recurrence because it fails to remove the cyst wall 1, 2
• The entire cavity must be thoroughly evacuated, with all loculations broken up using blunt dissection 2
• Multiple counter-incisions are preferred for large lesions rather than a single long incision 6

Antibiotic Use: Critical Decision Points

Antibiotics are rarely necessary for inflamed sebaceous cysts unless specific high-risk criteria are met. 1, 2

Antibiotics Are NOT Indicated When:

• Erythema extends <5 cm from the lesion 2
• Temperature <38.5°C 2
• Heart rate <110 beats/minute 2
• WBC count <12,000 cells/µL 2
• No systemic signs of infection present 2

Antibiotics ARE Indicated When:

• Temperature ≥38.5°C or systemic inflammatory response syndrome present 2, 6
• Heart rate >110 beats/minute 2, 6
• Erythema extending >5 cm from margins 2, 6
• Severely immunocompromised host (e.g., patients on immunosuppressive therapy like Benlysta) 6
• Incomplete source control after drainage 2
• Multiple lesions or extensive surrounding cellulitis 1, 2

Antibiotic Selection When Indicated:

• First-line: Trimethoprim-sulfamethoxazole for MRSA coverage 2, 6
• Alternatives: Clindamycin or doxycycline 2, 6
• Duration: 5-10 days based on clinical response 2, 6

Culture Recommendations

Gram stain and culture of inflamed epidermoid cysts are NOT recommended in immunocompetent patients, as they contain normal skin flora and inflammation is not primarily infectious. 2

• Cultures should be obtained in immunocompromised patients even for simple-appearing lesions 6
• Consider dermatology or infectious disease consultation for immunocompromised patients with atypical, multiple, or non-responsive lesions 6

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

Management of Recurrent Lesions

For recurrent cysts, implement a 5-day decolonization regimen: 6

• Intranasal mupirocin 6
• Daily chlorhexidine body washes 6
• Decontamination of personal items 6

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, as most inflamed cysts represent sterile inflammation from wall rupture, not bacterial infection requiring antibiotics 1
• Simple incision and drainage is an outdated approach that fails to address the cyst wall and has high recurrence rates 1, 2
• Failing to perform adequate drainage when infection is present—antibiotics alone are insufficient 2, 6
• Missing systemic signs can lead to unnecessary antibiotic use or inadequate treatment—always check vital signs and extent of erythema 2, 6

Special Considerations

• For multiple giant sebaceous cysts covering extensive areas (e.g., entire scrotal skin), all cysts should be removed in toto due to the unusual presentation 3
• Long-standing cysts, particularly large ones (>5 cm), require histopathological examination to exclude rare malignant transformation 7, 8
• In cases requiring extensive scrotal wall removal, appropriate coverage of the testicles must be ensured 3