What is the best treatment approach for a patient with an epidermal inclusion cyst?

Treatment of Epidermal Inclusion Cysts

For uncomplicated epidermal inclusion cysts, surgical excision with complete removal of the cyst wall is the definitive treatment to prevent recurrence, with the specific technique chosen based on cyst size and location. 1, 2

Surgical Approach Based on Clinical Characteristics

Small to Medium Cysts (1-2 cm) in Cosmetically Sensitive Areas

• Punch incision technique is superior for cysts measuring 1-2 cm located on the face or areas of cosmetic concern, producing shorter wound length (0.73 cm vs 2.34 cm), faster operative time (12.7 vs 21.6 minutes), and equivalent recurrence rates compared to elliptical excision 2
• This minimally invasive approach achieves excellent cosmetic outcomes while maintaining low recurrence rates 2

Larger or Multiple Cysts

• Wide local excision with complete removal of the entire cyst wall is necessary to prevent recurrence, particularly for infected or progressively enlarging cysts 1
• Marker sutures should be used during excision to properly orient the specimen for histopathological evaluation 1
• For multiple facial cysts with signs of infection (pain, tenderness, progressive size increase over 3 months), complete surgical excision is medically necessary rather than cosmetic 1

Alternative for Large Cysts in Aesthetically Important Areas

• Erbium:YAG laser fenestration may be considered as an alternative when patients are concerned about scarring, particularly for large lesions in aesthetically important areas 3
• This technique achieved satisfactory cosmetic outcomes in 23 of 25 patients with rapid healing, minimal invasiveness, and no scar formation 3
• Two patients required subsequent elective excision after cyst size reduction, with scars well-hidden 3

Essential Diagnostic Considerations

Pre-operative Evaluation

• Ultrasound confirmation of infected cystic lesions provides objective evidence when clinical signs of inflammation are present 1
• Physical examination should confirm that masses are soft and mobile to distinguish from other diagnoses 4
• MRI may be warranted for large or complex masses to confirm diagnosis and rule out alternative pathology such as neurofibromatosis 4

Histopathological Examination

• Histopathological evaluation is medically necessary to confirm diagnosis, determine whether margins are clear, and assess for any atypical features requiring additional treatment 1
• This is particularly important for multiple cysts or those with atypical presentations to avoid diagnostic errors 4

Critical Pitfalls to Avoid

• Do not treat infected or progressively enlarging cysts as merely cosmetic concerns, as this can lead to progression and worse outcomes 1
• Incomplete removal of the cyst wall leads to recurrence—ensure complete excision of the entire cyst capsule 1, 5
• Do not assume diagnosis without appropriate imaging or histopathological confirmation, especially when clinical presentation is atypical or accompanied by other conditions 4
• Simple excision is adequate when diagnosis is confident; avoid unnecessarily extensive procedures (such as Sistrunk procedure for anterior neck EIC) 5

Special Anatomical Considerations

• For anterior neck epidermal inclusion cysts, simple excision is adequate when diagnosis can be made confidently intraoperatively, with no recurrences reported at mean 4.5-year follow-up 5
• For rare locations such as intersphincteric anal plane, careful mobilization and excision with attention to surgical technique reduces recurrence and patient morbidity 6