What are the appropriate treatments and management strategies for small cysts on the body?

Management of Small Body Cysts

For small cutaneous cysts (epidermoid, trichilemmal, sebaceous), observation is the primary management strategy unless the cyst becomes symptomatic, infected, or cosmetically concerning—at which point surgical excision is the definitive treatment.

Initial Assessment and Classification

The approach to small body cysts depends critically on their anatomic location and type:

Cutaneous/Subcutaneous Cysts

• Epidermoid cysts are the most common skin cysts and frequently become colonized with normal skin flora (Staphylococcus epidermidis, Corynebacterium acnes) even when clinically uninflamed, making them prone to secondary infection 1
• Trichilemmal cysts do not typically harbor bacteria and have lower infection risk compared to epidermoid cysts 1
• These lesions can be classified by age group and anatomic location to simplify the diagnostic approach 2

Ganglion Cysts (Wrist/Joint-Related)

• 50% of ganglion cysts resolve spontaneously without intervention, making watchful waiting a reasonable first-line approach 3
• Aspiration/injection has high recurrence rates, while surgical removal has lower recurrence but higher complication rates 3

Management Algorithm

For Asymptomatic Small Cutaneous Cysts (<2-3 cm)

• Observation is appropriate as these are benign lesions with no malignant potential 2
• Patient education about signs of infection (erythema, warmth, tenderness, purulent drainage) is essential 1
• No routine imaging or follow-up is required for typical presentation 2

For Symptomatic or Inflamed Cysts

• Surgical excision is the definitive treatment when cysts become painful, infected, or rapidly enlarging 2
• If acute infection is present, initial drainage with delayed definitive excision (after inflammation resolves) reduces recurrence risk 1
• Complete excision of the cyst wall is necessary to prevent recurrence 2

For Ganglion Cysts

• Initial watchful waiting for 6-12 months given the 50% spontaneous resolution rate 3
• If intervention desired: surgical excision preferred over aspiration due to lower recurrence (though higher complication risk) 3
• Aspiration alone has high recurrence rates and should be reserved for patients who decline surgery 3

Critical Pitfalls to Avoid

• Do not aspirate epidermoid cysts routinely—they contain keratin debris, not simple fluid, and aspiration does not address the cyst wall, leading to inevitable recurrence 1, 2
• Do not excise acutely inflamed/infected cysts—the inflammation makes complete wall removal difficult and increases recurrence; drain first, then excise after resolution 1
• Do not assume all "cysts" are benign—any atypical features (rapid growth, fixation to underlying structures, unusual location) warrant biopsy to exclude malignancy 2
• Recognize that cysts with a visible punctum (epidermoid cysts) are more prone to infection than those without (trichilemmal cysts) due to bacterial colonization 1

When to Refer for Specialist Evaluation

• Cysts in complex anatomic locations (face near vital structures, hands/wrists affecting function) 2
• Recurrent cysts after previous excision 2
• Multiple cysts suggesting underlying syndrome (e.g., steatocystoma multiplex) 1
• Any concern for malignancy based on atypical clinical features 2