Management of Sebaceous Cysts
Primary Treatment Recommendation
Surgical excision is the definitive treatment for sebaceous cysts, with complete removal of the cyst wall being essential to prevent recurrence. 1, 2, 3
Management Algorithm
For Uninfected Sebaceous Cysts
Standard excision with complete cyst wall removal is the gold standard approach. 1, 3 The key principle is ensuring complete removal of the cyst wall, as incomplete excision leads to recurrence. 1, 3
Surgical Technique Options:
Conventional wide excision: Remains the most reliable method for complete cyst removal, particularly for larger cysts 3
Minimal excision techniques: Appropriate for smaller cysts where cosmetic outcome is a priority 3
Two-stage laser-assisted approach: For large cysts or those in cosmetically sensitive areas, use a laser to create a small opening for content drainage, followed by minimal excision of the cyst wall approximately 1 month later 3
Intraoral approach: Specifically for cysts located in the lip or cheek near the lip commissure, an intraoral incision through the buccinator or orbicularis oris muscle avoids visible facial scarring 1
Location-Specific Considerations:
Facial/cosmetically sensitive areas: Consider the two-stage laser technique or minimal excision to minimize scarring 3
Perioral location: Use the intraoral approach to avoid external scars 1
Scalp: Multiple or giant cysts require standard excision with histopathological examination to rule out malignant transformation in long-standing cases 4
For Infected Sebaceous Cysts
Contrary to traditional incision and drainage, immediate excision with primary closure is now recommended for infected cysts. 2 This represents a paradigm shift from older management approaches.
Technique for Infected Cysts:
Excise the infected tissue along with a rim of healthy tissue under local or general anesthesia 2
Perform primary closure with non-absorbable suture (Prolene) in the same sitting 2
Remove sutures on day 21 for back lesions and day 14 for limb lesions 2
This approach provides quicker recovery, eliminates the need for frequent dressings (reducing cross-infection risk), and is more cost-effective than traditional incision and drainage. 2
Critical Pitfalls to Avoid
Incomplete Cyst Wall Removal
The most common cause of recurrence is failure to remove the entire cyst wall during excision. 1, 3 Ensure meticulous dissection to identify and remove all wall components.
Misdiagnosis of Malignancy
Always send excised tissue for histopathological examination, particularly in:
- Long-standing cysts (risk of malignant transformation) 4
- Axillary location (can mimic ectopic breast carcinoma) 5
- Multiple giant cysts 4
A case report documented invasive ductal carcinoma presenting as an apparent axillary sebaceous cyst, emphasizing the importance of routine histopathology. 5
Inadequate Treatment of Infected Cysts
Do not default to simple incision and drainage for infected cysts—this prolongs treatment and increases infection risk. 2 Immediate excision with primary closure is superior.