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Safer and less unpleasant incision and drainage of epidermal inclusion cysts.

Letter to the Editor: A number of methods exist for the treatment of epidermal inclusion cysts. Intralesional steroids can be employed for mildly inflamed lesions, where in some cases not only inflammation but also the entire lesion may resolve with this modality. Piezosurgery can be used for small cysts. A small incision is made overlying the cyst through which the intact lesion is expressed by the application of pressure deep to the cyst. This method is notable for its cosmetically pleasing results. Enucleation of small to medium-sized lesions can be done by punching directly into the cyst’s upper surface followed by extraction of the cyst’s glistening capsule, grasped with toothed forceps or hemostat gently rotated in a clockwise or counterclockwise direction. Elliptical excision can be done for larger lesions where the wall of the lesion must be dissected out to ensure a low risk of recurrence. Incision and drainage may be required for large inflamed lesions combined with temporarily packing the area with a gauze wick and appropriate antibiotic coverage and cultures. The method involves incising into the cavity of the inflamed lesion and the application of lateral pressure to the side walls of the lesion by the surgeon’s gloved hand. It carries the troublesome risk of splashing the surgeon and assistants, and possibly any observers, like family members, who may be accompanying the patient to the office visit, with the cyst contents. Perhaps the risk of eye and mouth contact with the cyst contents carries the greatest risk, in that it inoculates potentially infectious biologic material onto mucous membrane surfaces. Wearing protective clothing and eyewear is usually recommended for such procedures.