Cysts are one of the more common skin lesions that we evaluate and treat in dermatology. Most patients simply want reassurance that they are harmless and not a sign of skin cancer, while others wish to have them treated regardless.
They are caused when the pore of an oil gland or hair follicle gets clogged. We literally have thousands of small follicles scattered throughout the surface of our skin. Within each follicle, there are skin cells which are supposed to gradually work their way to the surface and shed.
For a cyst to develop, all it takes is for one of these follicles to get clogged. This can happen for any variety of reasons – a small twist in the pore, the skin cells clump together and mix with the oil, etc.
Once the clog forms, the skins cells within the pore have nowhere to go, build up beneath the surface, and form the ‘lump’ that we recognize as the common ‘cyst’.
First, cysts generally don’t need to be treated. Unless one is prone to repeated inflammation or causing physical deformity, they’re really just a nuisance and otherwise pose no harm.
For this reason, insurance companies will often refuse coverage for the treatment of cysts which are not symptomatic (not growing, feeling painful, draining, etc.).
If removal is necessary, the question is how? There are two main options:
Incision and drainage
Incision and drainage is the formal name we use to describe draining or ‘lancing’ a cyst. Its primary advantage is that it can be performed easily in the office within a matter of minutes. If the cyst is painful or inflamed, incision and drainage provides immediate relief.
The disadvantage of treating a cyst by incision and drainage is that doing so simply removes the contents of the cyst, but not necessarily the entirety of the cyst itself. Refer to the diagram on the first page. Well-developed cysts usually have a ‘sac lining’ which may allow the cyst to re-develop if not removed. Therefore, incision and drainage can a) provide immediate relief and b) at least initially, give the appearance that the cyst is gone. However, the cyst may come back because the lining of the cyst simply ‘fills back up’ again.
Excision, on the other hand, is the method we use to completely remove the cyst – lining and all. Its primary advantage is that is offers the highest likelihood that the cyst will not return.
There are a few disadvantages to excision, though. First, excision is a formal surgical procedure which involves proper setup, instruments, and time allotment. In many clinics, excisions are only performed on certain ‘surgery days’.
Another disadvantage of excision is that it involves a slightly larger cut than that required for incision and drainage. Plus, once a cyst has been fully excised, the site is closed with stitches. After allowing 1-2 weeks to heal, a return office visit is then required for suture removal.
Finally, excision can’t be performed on an inflamed cyst. Many people don’t realize this, but cyst inflammation usually isn’t a sign of infection, but instead simply means that the cyst lining has ruptured. The body reacts to the cyst leaking from the broken lining, and redness and tenderness will form just as if an infection were occurring. Because the goal of excision is to remove the entire cyst, it can’t be performed until any ruptures have had time to heal.