Epidermal Cyst Treatment
First-Line Management
For uncomplicated epidermal cysts, incision and drainage (I&D) with complete evacuation of contents and thorough probing to break up loculations is the recommended first-line treatment. 1, 2
Treatment Algorithm
For Inflamed/Symptomatic Cysts
- Perform incision and drainage as the definitive initial treatment 2, 3
- Make a 2-3mm incision, express cyst contents through compression, and extract the cyst wall through the incision 4
- Probe the cavity thoroughly to break up any loculations or septations—this is critical to prevent treatment failure 5, 2
- Cover with a simple dry sterile dressing—do NOT pack the wound with gauze as this increases pain without improving healing 1, 5, 2
- Antibiotics are NOT routinely indicated 1, 2
When to Add Antibiotics
Antibiotics should be added ONLY if any of the following are present:
- Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachycardia >90 bpm, tachypnea >24 breaths/min, or WBC >12,000 or <4,000 cells/µL 5, 2
- Extensive surrounding cellulitis (>5 cm of erythema with induration) 1, 5
- Severely impaired host defenses or immunocompromised state 1, 2
- Use an antibiotic active against MRSA if the patient has markedly impaired host defenses or SIRS 2
For Uninflamed/Asymptomatic Cysts
- Observation is appropriate for small, asymptomatic cysts, particularly in cosmetically sensitive areas like the face in infants 3
- Elective complete surgical excision can be performed when inflammation has subsided—this removes the entire cyst wall and minimizes recurrence risk 6, 7, 4
- The minimal excision technique (2-3mm incision with cyst wall extraction) is less invasive than complete elliptical excision and does not require suture closure 4
Critical Management Points
What NOT to Do
- Do NOT culture or obtain Gram stain from inflamed epidermoid cysts—the inflammation typically results from rupture of the cyst wall and extrusion of contents into the dermis, not bacterial infection 1, 2
- Do NOT prescribe antibiotics without addressing the mechanical problem—antibiotics alone without adequate drainage will fail 5
- Do NOT pack the wound—this causes unnecessary pain without improving outcomes 5, 2
- Do NOT perform needle aspiration—it has only 25% success rate overall and <10% success with MRSA infections 2
Ensuring Treatment Success
- Complete evacuation is essential—inadequate initial drainage is the most common cause of treatment failure and recurrence 5
- Most wounds should heal within 2-3 weeks with simple dry dressing changes 5
- If drainage persists beyond 3 weeks, re-open the incision and ensure complete evacuation of all contents 5
When to Consider Complete Excision
Complete surgical excision with removal of the entire cyst wall should be considered for:
- Recurrent cysts after failed I&D 5, 6, 7
- Cosmetic concerns in visible areas (though timing should minimize scarring, especially on the face) 3, 8
- Suspicious features suggesting possible malignant transformation (rapid growth, ulceration, unusual appearance) 3, 9
- All excised specimens should undergo histopathological examination, as malignant transformation to squamous cell carcinoma, though rare, can occur 7, 9
Special Considerations
Facial Cysts in Infants
- Conservative management with observation is preferred 3
- Intervention indicated only for signs of infection, rapid growth, ulceration, bleeding, or functional impairment 3
- Consult pediatric dermatology or plastic surgery if surgical intervention is required 3