Sebaceous Cyst Treatment
The primary treatment for sebaceous cysts is complete surgical excision with removal of the entire cyst wall to prevent recurrence, performed under local anesthesia with an elliptical incision and 2mm margin of normal skin. 1, 2
Treatment Approach Based on Clinical Presentation
Uninfected/Non-inflamed Cysts
- Complete excision under local anesthesia is the definitive treatment, using an elliptical incision with the long axis parallel to skin lines for optimal cosmetic results 2
- The entire cyst wall must be removed to prevent recurrence 1
- Excise with a narrow 2mm rim of normal skin 2
- Use a scalpel rather than laser or electrocautery to preserve histological features 2
- Cover the surgical site with a simple dry dressing 1, 2
- All excised tissue must be sent for histopathological examination 2
Infected/Inflamed Cysts
One-stage excision of infected sebaceous cysts is superior to the conventional two-stage approach (initial drainage followed by delayed excision), as it decreases antibiotic exposure, reduces morbidity, and is more cost-effective 3
Primary Treatment Strategy:
- Incision and drainage is the cornerstone treatment for infected cysts 1
- Thorough evacuation of pus and probing the cavity to break up all loculations is essential 4, 1
- The entire cyst wall should ideally be excised in the same sitting under appropriate anesthesia to prevent recurrence 1
- One-stage excision followed by 5 days of antibiotics is preferable to conventional staged treatment 3
Antibiotic Indications:
Systemic antibiotics are generally unnecessary after adequate drainage unless specific criteria are met 4, 1
Antibiotics are NOT needed when:
- Erythema extends <5cm from the lesion 1
- Temperature <38.5°C 1
- Heart rate <110 beats/minute 1
- WBC count <12,000 cells/µL 1
- No systemic signs of infection 4, 1
Add systemic antibiotics when:
- Temperature ≥38.5°C or systemic inflammatory response syndrome present 1
- Heart rate >110 beats/minute 1
- Erythema extending >5cm from margins 1
- Severely immunocompromised host 1
- Incomplete source control after drainage 1
- Multiple lesions or extensive surrounding cellulitis 4, 1
Antibiotic selection for MRSA coverage:
- Trimethoprim-sulfamethoxazole, clindamycin, or doxycycline 1
- Duration: 5-10 days based on clinical response 1
Special Considerations for Resolving Infected Cysts
- For a resolving infected cyst with no systemic symptoms, incision and drainage alone is sufficient 4
- Systemic antibiotics are unnecessary unless extensive cellulitis or systemic signs present 4
- Gram stain and culture are rarely necessary for uncomplicated, drained cysts 4, 1
Indications for Hospital Admission
Most infected sebaceous cysts can be managed in outpatient settings 2
Admit to hospital when:
- Signs of systemic toxicity (fever, tachycardia, tachypnea, hypotension) 2
- Extensive surrounding cellulitis indicating spreading infection 2
- Severely impaired host defenses 2
- Multiple lesions with severe systemic manifestations 2
- Suspected necrotizing infection requiring aggressive surgical debridement 2
Alternative Minimally Invasive Techniques
- CO2 laser punch-assisted surgery can be considered for cosmetically sensitive areas, with acceptable recurrence rates (0% for uninfected, 16.7% for infected cysts) and high patient satisfaction 5
- Intraoral approach for cysts in the lip or cheek near lip commissure avoids visible facial scarring 6
Critical Pitfalls to Avoid
- Failing to perform adequate incision and drainage is the most critical error, as antibiotics alone are insufficient 1
- Prescribing antibiotics unnecessarily when adequate drainage has been performed shows no significant benefit 1
- Incomplete evacuation of purulent material and failure to break up all loculations leads to treatment failure 1
- Not removing the entire cyst wall results in recurrence 1
- Overuse of antibiotics contributes to antimicrobial resistance 4