In a patient with a 1 cm mobile, non‑inflamed scalp cyst that the patient reports has been slowly enlarging over a year, should I proceed with elective surgical excision?

Management of a 1 cm Slowly Enlarging Scalp Cyst

Proceed with elective surgical excision now, as the documented enlargement over one year—even if self-reported—mandates removal according to NCCN guidelines. 1

Rationale for Immediate Excision

The National Comprehensive Cancer Network explicitly states that a "watch-and-wait" approach is appropriate only for scalp cysts that remain stable in size without any evidence of growth. 1 Your patient's cyst has demonstrated progressive enlargement over 12 months, which disqualifies observation as a management option.

Why Self-Reported Growth Matters

• NCCN guidelines recommend excision of any sebaceous cyst that increases in size on follow-up examination, as enlargement may indicate potential malignancy. 1
• The fact that growth is self-reported rather than clinician-documented does not negate the indication for excision—the patient has observed a change that warrants intervention. 1
• If you had chosen observation initially, NCCN protocols would have required clinical examination every 6–12 months with immediate surgical excision mandated should any further enlargement be detected. 1 Your patient has already crossed this threshold.

Additional Indications Supporting Excision

Beyond the documented growth, several other factors favor surgical removal:

• The cyst is mobile and non-inflamed, making this an ideal time for excision with optimal surgical conditions and lower complication risk. 2
• Inflamed cysts are technically difficult to excise completely, and it is preferable to postpone excision until inflammation subsides. 2 Your patient's lack of inflammation represents a favorable surgical window.
• The minimal excision technique for epidermoid cysts is straightforward, involving a 2–3 mm incision with expression of contents and extraction of the cyst wall, without requiring suture closure. 2
• Recurrence rates with proper technique are extremely low (0.66% in one series of 302 patients over 18 months). 3

What Observation Would Have Required

Had the cyst remained stable, NCCN guidelines would permit observation with:

• Clinical examination every 6–12 months 1
• Immediate excision if any enlargement detected 1

Your patient has already met the threshold for mandatory excision by demonstrating growth. 1

Surgical Approach

• Use the minimal excision technique: 2–3 mm incision, express cyst contents, extract the cyst wall intact. 2
• Protect yourself from spraying cyst contents with gauze or a splatter shield. 2
• Complete removal of the cyst wall is essential to prevent recurrence. 2, 3

Pathology Considerations

• Routine histologic evaluation is not necessary unless you encounter unusual findings during excision or have clinical suspicion of malignancy. 2
• The rarity of associated cancer in epidermoid cysts makes universal pathologic examination unnecessary for typical presentations. 2

Critical Pitfall to Avoid

Do not delay excision waiting for further "objective" documentation of growth. The patient has already reported progressive enlargement over one year, which is sufficient to trigger the NCCN mandate for immediate surgical removal. 1 Continued observation would be inconsistent with guideline recommendations and could allow a potentially concerning lesion to grow further.