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What's the Best Treatment for Sebaceous Cysts?

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What's the Best Treatment for Sebaceous Cysts? From the CLINIcAL InQUIRIES Family Physicians Inquiries Network R. Brian Moore, MD, What’s the best treatment E. Blake Fagan, MD, Stephen Hulkower, MD, and for sebaceous cysts? Deborah C. Skolnik MLS Mountain Area Health Education Center, Asheville, NC Evidence-based answer Punch biopsy excision appears to be based on 1 small randomized study). No superior to traditional wide elliptical rigorous methodological studies have excision for the treatment of sebaceous compared punch biopsy excision of cysts when intervention is necessary sebaceous cysts with the minimal excision (strength of recommendation [SOR]: B, technique. Clinical commentary ® Cyst qualities dictate technique Dowdenresult because ofHealth the significantly Media smaller There are 3 main techniques for the scar. removal of sebaceous cysts:Copyright traditional However, for a cyst that has ruptured wide excision, minimal excision, andFor personalinternally, has beenuse expressed only manually punch biopsy excision. For large cysts in the past, or recurs following minimal that have never become inflamed or excision, I find traditional wide excision to ruptured, I favor the minimal excision be best. In these scenarios, it is extremely technique because it’s likely that I’ll be time-consuming and often impossible FAST TRACK able to remove the entire capsule with to remove the entire capsule using the Punch and minimal scarring and faster healing minimal excision technique. times. Also, for cysts on the face, this minimal excision method produces a better cosmetic Gabrielle O’Sullivan, MD University of Washington, Seattle biopsy may have faster healing times and produce z Evidence summary ered the gold standard of treatment. This Sebaceous cysts—more correctly re- time-consuming endeavor frequently leads less scarring ferred to as epidermal inclusion cysts— to significant scarring in comparison with are benign lesions of the skin. They rare- minimal excision or punch biopsy, but has ly require intervention out of medical almost no recurrence when the cyst wall is necessity, but are removed for cosmetic entirely removed.2 reasons. If the cysts become inflamed, Minimal excision and punch biopsy secondary to internal discharge of the techniques are purported to produce min- cysts’ contents, or grow so large that imal bleeding, have faster healing times, they interfere with the patient’s func- and produce less scarring.2 Though both tioning, they may need to be removed.1 techniques offer a shorter procedural time, Traditional wide excision—involv- they appear to have a slightly higher rates ing dissection and removal of the cyst of recurrence. completely from the surrounding tissue The minimal incision technique in- through an elliptical incision—is consid- volves kneading the lesion following www.jfponline.com VOL 56, NO 4 / APRIL 2007 315 For mass reproduction, content licensing and permissions contact Dowden Health Media. QUIRIES In injection of anesthetic and expressing Recommendations from others the cyst contents through a 2- to 3-mm UpToDate does not recommend excision AL c incision. Following expulsion of the cyst of an inflamed cyst, suggesting that the contents, the loosened capsule is deliv- inflamed cyst wall is more friable and, ered through the small opening. Closure therefore, more difficult to remove com- CLINI with suture is optional.3 pletely.7 This may lead to a higher rate of Punch biopsy excision is similar to recurrence. the minimal excision technique except Lookingbill and Marks in Principles that the incision is made using a single- of Dermatology8 suggest that, frequently, use disposable dermal punch following no therapy is indicated for these lesions. If injection of lidocaine. Expulsion of the removal is desired or indicated, every ef- cyst contents, with cyst wall, via lateral fort should be made to remove the entire pressure is performed and occasionally cyst lining in order to prevent recurrence followed by closure with one suture.2 of the cyst. They recommend removal of The majority of authors agree that the cyst via the traditional wide excision inflamed cysts should be allowed to technique. If the cyst ruptures accidentally convalesce prior to attempted remov- during the procedure they suggest remov- al, though one group (Kitamura et al4) ing the remaining contents and wall with suggests primary resection, wound a curette. n lavage, and primary suture without drainage for infected epidermal cysts. References Rarely are these cysts truly infected. The 1. GP Notebook [online database]. Stratford-on-Avon, Warwickshire, UK: Oxbridge Solutions Limited; inflammation is secondary to sebaceous 2003. Sebaceous cyst. Available at: www.gpnote- cyst wall rupture with leakage of cyst book.co.uk. Accessed on March 7, 2007. contents, which elicits the inflammatory 2. Mehrabi D, Leonhardt JM, Brodell RT. Removal of keratinous and pilar cysts with the punch incision 5 response. technique: analysis of surgical outcomes. Dermatol Surg 2002; 28:673–677. 3. Zuber TJ. Minimal excision technique for epider- A small study points to cosmetic moid (sebaceous) cysts. Am Fam Physician 2002; FAST TRACK benefits of punch biopsy 65:1409–1412,1417–1418,1420. To date, no randomized controlled trials 4. Kitamura K, Takahashi T, Yamaguchi T, Shimotsuma A small study found M, Majima T. Primary resection of infectious epider- punch biopsy have been published that compare the mal cyst. J Am Coll Surg 1994; 179:607. 3 most common techniques for treat- 5. Diven DG, Dozier SE, Meyer DJ, Smith EB. Bacteri- to have better ment of sebaceous cysts. Only 1 small ology of inflamed and uninflamed epidermal inclu- sion cysts. Arch Dermatol 1998; 134:49–51. cosmetic results (n=60) randomized study compared 6. Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. traditional wide excision with punch Comparison of the surgical outcomes of punch in- and to take 6 cision and elliptical excision in treating epidermal biopsy. They found punch biopsy to inclusion cysts: a prospective, randomized study. less time than be less time-consuming and to offer Dermatol Surg 2006; 32:520–525. the traditional superior cosmetic results. However, cysts 7. Goldstein BG, Goldstein AO. Benign neoplasms of the skin. UpToDate [online database]. Updated No- wide excision larger than 2 cm took longer with the vember 21, 2005. Waltham, Mass: UpToDate. punch biopsy technique. 8. Lookingbill DP, Marks JG. Principles of Dermatology. 3rd ed. Philadelphia, Pa: WB Saunders Company; Only a single dermatologist per- 2000. formed all of the surgeries, which could introduce bias. There was no mention of blinding of the researcher that sub- sequently measured the wounds. Of the 31 patients randomized to the punch biopsy technique, there was 1 recurrence in the 16 months of follow-up compared with none in the wide excision arm. This study excluded patients with infected, inflamed, or recurrent cysts. 316 VOL 56, NO 4 / APRIL 2007 THe JOURNAL OF FAmILY PRActIce.
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