Cyst on Palm of Hand: Diagnosis and Management
Most Likely Diagnoses
A cyst on the palm is most commonly either a ganglion cyst or an epidermoid inclusion cyst, with ganglion cysts being the most frequent hand tumor overall, though epidermoid cysts are the second most common hand mass. 1, 2
Key Distinguishing Features
Ganglion Cysts:
- Soft, fluid-filled swellings that are typically asymptomatic aside from the visible mass 3
- May cause pain, weakness, or paresthesias in some cases 3
- Most commonly affect women in their twenties and thirties, though palmar presentations can occur in older patients (>65 years) 4
- Arise adjacent to joints and tendons 5
Epidermoid Inclusion Cysts:
- Contain cheesy keratinous material with normal skin flora even when uninflamed 1
- Rare in hairless areas like the palm, but can develop secondary to trauma that drives epithelial cells into subcutaneous tissues 6, 2
- Inflammation occurs from cyst wall rupture, not true infection 1
Diagnostic Approach
Clinical examination alone is adequate for classic presentations of either lesion. 1
For atypical presentations, ultrasound is the first-line imaging modality with 94.1% sensitivity and 99.7% specificity for superficial soft-tissue masses, confirming the fluid-filled nature of ganglion cysts versus solid epidermoid cysts. 1
Management Strategy
For Ganglion Cysts:
Observation is the preferred initial approach, as 58% of ganglion cysts resolve spontaneously over time. 3
- Conservative treatment (aspiration) is largely ineffective long-term but can provide symptomatic relief for patients who decline surgery 3
- Aspiration has a recurrence rate >50% for most locations, though <30% for flexor tendon sheath cysts 5
- Surgical excision is indicated for persistent pain, interference with activity, nerve compression, or patient preference for definitive treatment, with a recurrence rate of only 5% when the stalk and small portion of joint capsule are completely excised 5
- Follow-up protocol should include physical examination and/or ultrasound every 6-12 months for 1-2 years to ensure stability 1
For Epidermoid Cysts:
When inflamed, incision and drainage should include thorough evacuation, probing the cavity to break loculations, and dry dressing without packing in most cases. 1
Antibiotics are rarely needed and should be reserved only for:
Definitive treatment requires complete surgical excision of the cyst wall to prevent recurrence. 6, 2
Critical Pitfalls to Avoid
- Do not routinely prescribe antibiotics for inflamed epidermoid cysts—inflammation is from cyst wall rupture, not bacterial infection 1
- Do not rush to surgery for ganglion cysts without first offering observation, as most resolve spontaneously 3
- Ensure complete excision of ganglion cyst stalk and capsule during surgery to minimize the 5% recurrence rate 5
- Do not pack the cavity after incision and drainage of epidermoid cysts in most cases 1