Chapter 94

Sebaceous cysts are common, may be located anywhere on the body, and frequently become infected. Patients will often present complaining of pain. The Emergency Physician must be acquainted with the principles involved in treating abscesses, particularly if they are located on cosmetically important areas such as the face.

Sebaceous cysts are the result of obstruction of sebaceous gland ducts. They are freely mobile, round, and located in the subcutaneous tissues. The cysts are made of a thin white capsule filled with a thick, cheesy, and keratinous material. They frequently become infected and subsequently form an abscess. Sebaceous cysts may be present for many years before infection occurs. Physical examination often reveals a subcutaneous mass that is fluctuant and tender. The overlying skin may appear normal or erythematous.

The initial treatment of an infected sebaceous cyst is incision and drainage. The sebaceous material is too thick to allow for spontaneous drainage and it must be expressed. The sebaceous cyst will likely recur, however, unless the capsule of the cyst is removed. Patients may have the initial incision and drainage performed in the Emergency Department with follow-up at some later date to remove the cyst capsule. Alternatively, the cyst capsule may be removed at the time of the initial incision and drainage.

Incision and drainage is indicated whenever a patient presents with a tender sebaceous cyst consistent with abscess formation. The procedure will relieve the patient’s pain. Antibiotics alone are ineffective in treating abscesses.1 The vast majority of infected sebaceous cysts may be drained in the Emergency Department, clinic, or office setting. A noninfected sebaceous cyst may be removed electively and for cosmetic purposes in the clinic or office setting by the Primary Care Provider or a Surgeon.

There are no absolute contraindications to the incision and drainage or removal of an infected sebaceous cyst. Incision and drainage is preferred if the overlying skin is cellulitic. The capsule can be removed at a later time. Extremely large abscesses or those in which adequate anesthesia is not possible should be managed in the Operating Room by a General Surgeon or Plastic Surgeon. Refer patients with noninfected sebaceous cysts to their Primary Care Provider or a Surgeon for removal.

• Povidone iodine solution
• 10 mL syringe
• 25 to 30 gauge needle, 2 inches long
• Local anesthetic solution, with or without epinephrine
• #11 scalpel blade on a handle
• #15 scalpel blade on a handle
• Curved hemostat
• Iris scissors
• Ribbon gauze, plain or iodinated
• 4×4 gauze squares
• Sterile saline
• Nylon sutures for skin closure, various sizes

Explain the risks, benefits, and potential complications of the procedure to the patient and/or their representative. The post-procedure care should be explained as well. Document the discussion of the risks and benefits of the procedure. Obtain an informed consent for the procedure.

### Anesthesia

Local anesthesia should be administered, recognizing that ...

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