What are the criteria for referring a patient with a sebaceous cyst to general surgery for removal, considering their overall health, medical history, and potential risks?

Criteria for Surgical Referral of Sebaceous Cysts

Most sebaceous (epidermoid) cysts can be managed in primary care with simple incision and drainage or excision, and surgical referral is rarely necessary unless specific high-risk features are present.

Primary Care Management is Appropriate For

Standard uncomplicated cysts should be managed without surgical referral, as effective treatment involves straightforward incision, thorough evacuation of contents, probing to break up loculations, and dry dressing application 1. The procedure typically takes 13 minutes and can be performed under local anesthesia 2.

• Systemic antibiotics are rarely necessary and should be reserved only for specific complications 1
• Simple excision with minimal surgical trauma achieves recurrence rates as low as 0.66% in primary care settings 3

Indications for General Surgery Referral

Absolute Indications

• Multiple lesions requiring coordinated surgical planning 1
• Cutaneous gangrene complicating the cyst 1
• Severely impaired host defenses (immunocompromised patients, uncontrolled diabetes) 1
• Extensive surrounding cellulitis that extends beyond local inflammation 1
• Severe systemic manifestations including high fever or sepsis 1

Relative Indications Based on Size and Location

• Giant cysts (>10 cm) that may require extensive dissection and complex closure 4
• Multiple large cysts (≥7 lesions) requiring staged procedures 4
• Anatomically complex locations where specialized surgical expertise improves outcomes:
  • Deep facial cysts near neurovascular structures 5
  • Cysts in cosmetically sensitive areas where intraoral approaches may be preferred 5
  • Scalp cysts with extensive involvement 4

Long-Standing Cysts Requiring Evaluation

• Cysts present since childhood that have grown to enormous size should be referred for excision with histopathological examination to rule out malignant transformation, though this is rare 4

Common Pitfalls to Avoid

Do not refer routine inflamed epidermoid cysts thinking they require antibiotics or specialized care - the inflammation typically results from cyst wall rupture and extrusion of contents into the dermis rather than true infection 1, 6. Simple drainage is curative in most cases 1.

Do not delay treatment of infected cysts - they can be excised with primary closure in the same sitting under local anesthesia, achieving quick recovery without need for frequent dressing changes 7.

Recognize that "sebaceous cysts" is a misnomer - these are actually epidermoid cysts containing keratinous material and skin flora even when uninflamed 1, 6.

Practical Algorithm for Decision-Making

Step 1: Assess for absolute contraindications to office management

• Immunocompromised state?
• Systemic signs (fever, sepsis)?
• Extensive cellulitis beyond local area?
• If YES → Refer to surgery 1

Step 2: Evaluate cyst characteristics

• Size >10 cm or multiple giant cysts?
• Complex anatomic location (deep facial, near vital structures)?
• If YES → Consider surgical referral 5, 4

Step 3: For standard cysts

• Perform incision and drainage or minimal excision under local anesthesia 1, 3
• Reserve antibiotics only for complications listed above 1
• Follow up to ensure resolution 3