How to treat an inflamed and infected sebaceous cyst?

The sebaceous cysts refer to initially harmless lumps that slowly develop under the skin and contain fluid and a semi-solid substance. They typically appear on the scalp, face, trunk, and back, that is, on parts of the body that house numerous sebaceous glands. These lumps usually occur following the rupture of a hair-sebaceous follicle, due to an accumulation of sebum and keratin within the structure. It is also suggested that some sebaceous cysts have a genetic origin. The cysts may maintain their initial size or gradually grow. Sometimes, they become inflamed or suddenly rupture, thereby posing a risk of infection.

The interior of a sebaceous cyst, composed of keratin and sebum, is typically protected by a thin membrane, known as a capsule or cystic wall, made of epidermal and keratinised cells, separating the internal mass from the surrounding tissues and the exterior. However, when the surface of the sebaceous cyst is weakened, due to repeated friction or manipulation for instance, it can crack and provide an opportunity for bacteria present on the skin surface, such as Cutibacterium acnes and Staphylococcus aureus, to penetrate into the cyst.

Once the bacteria are inside, they multiply rapidly due to the sebum and cellular debris they find, which serve as nutrients. In response to bacterial colonisation within the sebaceous cyst, the body triggers an immune response, leading to the formation of pus, a mixture of bacteria, cells and neutrophils, which are white blood cells. However, the pus increases the pressure inside the sebaceous cyst, causing visible swelling. The cyst then becomes red and painful, indicating local inflammation.

It is also possible for a sebaceous cyst to become inflamed even when there is no bacterial colonisation. This inflammation, termed aseptic, is often the result of the rupture of the cyst's wall within the skin. This event triggers the release of sebum and keratin from the sebaceous cyst into the surrounding tissues, which in turn initiates an inflammatory response. Macrophages are then mobilised to phagocytose these debris, but this creates redness and a sensation of heat in the area. The wearing of tight clothing or rubbing at the site of the sebaceous cyst can exacerbate the inflammatory processes by inducing local irritation and facilitating the rupture of the cystic wall, and thus the penetration of bacteria.

Only a healthcare professional is capable of identifying an inflamed or infected sebaceous cyst and treating it. Therefore, when a sebaceous cyst becomes a cause for concern or at the onset of initial symptoms, it is recommended to have it examined by a dermatologist. They can accurately diagnose and prescribe an appropriate treatment. In the case of an infection of a sebaceous cyst, antibiotics to be taken for 5 to 7 days are generally prescribed. To alleviate the patient in case of severe pain, it is also possible to empty the cyst by draining it with a syringe or by making an incision.

It is impossible to remove a sebaceous cyst when it is infected and in an inflammatory phase.

Indeed, the inflammation of the cyst renders local anaesthesia ineffective and hinders the clean dissection of the cyst as the skin tissues are clumped together. Furthermore, during an inflammatory episode, the skin tends to heal poorly, which exposes the risk of scar opening in the post-operative phase. That's why it is advised to wait six to eight weeks, a period allowing the skin inflammation to completely disappear and the cyst to return to its original size.

In addition to the treatments prescribed by the dermatologist, it is recommended to wash the area of the sebaceous cyst at least once a day and cover it with a clean dressing, which should be changed after each wash. Dressings help to limit friction that can sustain inflammation and cause pain. If the infected sebaceous cyst develops into an abscess, daily nursing care becomes necessary. This begins with a significant irrigation of the cavity using a saline solution, in order to reduce the bacterial load. A wick, a special type of dressing, is then inserted to keep the wound open and allow continuous drainage of pus.

• ZUBER T. & al. Minimal Excision Technique for Epidermoid (Sebaceous) Cysts. American Family Physician (2002).

• SOLIVETTI F. & al. Sonographic appearance of sebaceous cysts. Our experience and a review of the literature. International Journal of Dermatology (2019).

• MEENA V. & al. Sebaceous cyst: an unusual site of presentation & case report. Global Journal for Research Analysis (2023).