Treatment of Epidermal Inclusion Cysts
For symptomatic, infected, or enlarging epidermal inclusion cysts, complete surgical excision with removal of the entire cyst wall is the definitive treatment to prevent recurrence and complications. 1
Indications for Surgical Intervention
Infected or inflamed cysts require surgical excision, particularly when presenting with pain, tenderness, or progressive enlargement over 3 months. 1 These represent active pathology requiring medical intervention rather than cosmetic treatment. 1
- Multiple cysts in cosmetically or functionally sensitive areas (especially the face) warrant complete surgical excision to prevent complications and optimize outcomes. 1, 2
- Ultrasound or MRI confirmation of cystic lesions provides objective evidence supporting the medical necessity of intervention. 1, 2
Surgical Technique
Wide local excision with complete removal of the entire cyst wall is essential to prevent recurrence. 1 Incomplete excision leaving residual cyst wall epithelium leads to recurrence. 3
- Use marker sutures during excision to properly orient the specimen for histopathological evaluation. 1
- For facial lesions, careful surgical technique minimizes scarring while ensuring complete removal. 1, 2
- Simple excision is adequate when the diagnosis is confidently established intraoperatively. 3
Histopathological Examination is Mandatory
All excised cysts require histopathological evaluation to confirm the diagnosis, assess margin clearance, and exclude atypical features or malignant transformation. 1, 4, 5
- This is medically necessary to determine whether lateral and deep margins are clear of pathology. 1
- Histopathology identifies any atypical features requiring additional treatment. 1
Alternative Treatment for Select Cases
Erbium:YAG laser fenestration may be considered for large cysts in aesthetically important areas when patients are concerned about scarring. 6 This technique showed satisfactory cosmetic outcomes in 23 of 25 patients with rapid healing and minimal invasiveness. 6 However, this remains an alternative approach, not first-line treatment.
Management of Asymptomatic Stable Cysts
Asymptomatic stable lesions with typical sonographic and clinical findings do not require treatment; follow-up imaging suffices and biopsy is unnecessary. 4 However, excision is recommended for enlarging lesions to obtain definitive histopathological diagnosis and prevent potential malignant transformation. 4
Critical Pitfalls to Avoid
- Never treat multiple infected facial cysts as merely cosmetic, as this leads to progression of infection and worse outcomes. 1
- Do not perform incomplete excision, as leaving cyst wall remnants guarantees recurrence. 1, 3
- Avoid misdiagnosis by obtaining proper radiologic evaluation and pathologic confirmation, particularly when masses are multiple or associated with other conditions. 2