Epidermoid cysts (sebaceous cysts)

Definition

Epidermoid cysts

are small bumps that develop beneath the skin on your face, neck, trunk and sometimes your genital area. Slow-growing and often painless, they rarely cause problems or need treatment.
Although many people refer to epidermoid cysts as sebaceous cysts, they’re different. True sebaceous cysts are less common, and they arise from the glands that secrete oily matter that lubricates hair and skin (sebaceous glands). Epidermoid glands arise from the cells that make up the outer layers of skin (epidermal).
If the appearance of an epidermoid cyst bothers you, or if the cyst ruptures or becomes infected, it can be surgically removed. Epidermoid cysts are almost always noncancerous, but in rare cases, they can lead to skin cancers.

Symptoms

Epidermoid cysts:

• Are round cysts or small bumps that are easy to move with your fingers
• Are usually white or yellow, though people with darker skin may have pigmented cysts
• Range in size from less than 1/4 inch to nearly 2 inches (a few millimeters to 5 centimeters) in diameter
• Occur on nearly any part of your body, including your fingernails, but are found most often on your face, trunk and neck

Sometimes an epidermoid cyst has a central opening — the remnant of a hair follicle from which the cyst originally formed — that's plugged by a tiny blackhead. You may be able to squeeze out a thick, cheesy material through this opening, but because of the risk of infection and scarring, it's best to leave this to your dermatologist.

Milia — tiny, deep-seated whiteheads that never seem to come to the surface of your skin — are miniature epidermoid cysts. They're especially common in older women and in men with significant sun damage on their cheeks and temples. They can also be caused or aggravated by long-term use of oil-based creams or cosmetics.

Signs and symptoms of infection, which can occasionally occur, include:

• A thick, yellow material draining from the cyst that may have a foul odor
• Redness, swelling and tenderness around the cyst

A similar looking condition
Sometimes you may develop a small bump on your scalp that looks like an epidermoid cyst. These are almost always pilar or trichilemmal cysts, which usually have thicker walls than epidermoid cysts do and almost always move freely under your skin. The lining of this type of cyst differs slightly from that of an epidermoid cyst.

When to see a doctor
Most epidermoid cysts aren't harmful, but you may want to have them removed for cosmetic reasons. See your doctor if you have a cyst that:

• Grows rapidly
• Ruptures
• Becomes painful
• Occurs in a spot that's constantly irritated

Causes

The surface of your skin (epidermis) is made up of an extremely thin, protective layer of cells that your body continuously sheds. Most epidermoid cysts form when these surface cells, instead of exfoliating normally, move deeper into your skin and multiply. Most often, this occurs in areas where there are small hair follicles and larger oil glands (sebaceous glands), such as your face, neck, upper back and groin.

The epidermal cells form the walls of the cyst, and then secrete the protein keratin into the interior. The keratin is the thick yellow substance that sometimes drains from the cyst.

Several factors can lead to this abnormal proliferation of cells, including:

• Damage to a hair follicle. Each hair grows from a follicle, a small pocket of modified skin in the dermis, the layer of skin just below the epidermis. Follicles damaged by injuries, such as abrasions or surgical wounds, can become blocked by surface cells.
• A ruptured sebaceous gland. Located just above the hair follicles, sebaceous glands produce sebum, the oil that lubricates your skin and coats each hair shaft. These glands are easily ruptured by inflammatory skin conditions, especially acne, making them a likely site for epidermoid cysts.
• Developmental defect. Epidermoid cysts can begin in a developing fetus when stem cells intended to form skin, hair or nails become trapped in cells forming other tissues.
• Heredity. Epidermoid cysts can develop in people with Gardner's syndrome, a rare genetic disorder that causes growths in the colon, or basal cell nevus syndrome, an inherited disease that leads to several serious defects.

Risk factors

Nearly anyone can develop one or more epidermoid cysts, but these factors make you more susceptible:

• Being past puberty. Though they can occur at any age, epidermoid cysts rarely appear before puberty.
• Being male. Men are more likely to have epidermoid cysts.
• Having a history of acne. Epidermoid cysts are especially common in people who've had acne.
• Having significant sun exposure. Milia, seen mainly on the face, often occur in men and women with a long history of sun exposure.
• Experiencing skin injuries. Any traumatic or crushing injury to your skin — slamming your hand in a car door, for instance — increases your risk of an epidermoid cyst.

Complications

In rare cases, epidermoid cysts can give rise to basal and squamous cell skin cancers. Because this occurs so seldom, epidermoid cysts usually aren't biopsied unless they're solid, immobile, infected or have other unusual characteristics that suggest a more serious problem. Besides cancer, other complications include:

• Inflammation. Epidermoid cysts can become tender and swollen, even if they're not infected. Inflamed cysts are difficult to remove, and your doctor is likely to postpone treating them until the inflammation subsides.
• Rupture. A ruptured cyst often leads to a boil-like abscess that requires prompt treatment.
• Infection. An epidermoid cyst can become infected spontaneously or after a rupture.
• Genital discomfort. Genital epidermoid cysts can lead to painful intercourse and urination.

·         Preparing for your appointment

Your family doctor or general practitioner will likely be able to diagnose an epidermoid cyst based on its appearance. In some cases, however, you may be referred to a doctor who specializes in the diagnosis and treatment of skin conditions (dermatologist).

Here's some information to help you get ready for your appointment, and to know what to expect from your doctor.

What you can do

• Write down your key medical information, including other conditions for which you've been treated and any prescription or over-the-counter medications you're taking, including vitamins and supplements. Your doctor will want to know whether you've ever had acne — with or without cysts — that required treatment, and whether you have a family history of severe acne or multiple cysts.
• Note any recent injuries to your skin, including accidental wounds or scrapes as well as any surgical procedures.
• Write down questions to ask your doctor. Having a list of questions can help you make the most of your time with your doctor.

Below are some basic questions to ask your doctor about epidermoid cysts. If any additional questions occur to you during your visit, don't hesitate to ask.

• Do I have an epidermoid cyst?
• What causes this type of cyst?
• Is the cyst infected?
• What treatment approach do you recommend, if any?
• Will I have a scar after treatment?
• Am I at risk of this condition recurring?
• Is there anything I can do to help prevent a recurrence?
• Do epidermoid cysts increase my risk of other health problems?

What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:

• When did you notice this skin growth?
• Have you noticed any other skin growths?
• Have you had similar growths in the past? If so, on what parts of your body?
• Have you had severe acne with cysts?
• Is the growth causing any discomfort?
• Are you embarrassed by the growth?
• Have you had any recent skin injuries, including minor scrapes?
• Have you recently had a surgical procedure in the affected area?
• Does a tendency to form cysts run in your family?

What you can do in the meantime
Resist the urge to try to squeeze or "pop" your cyst. Your doctor will be able to take care of the cyst with the least risk of scarring and infection.

Tests and diagnosis

In most cases, your doctor can diagnose an epidermoid cyst based on its appearance, though he or she may refer you to a dermatologist for treatment.

Treatments and drugs

Cysts that don't cause cosmetic or functional problems are usually left alone. A cyst that's inflamed, ruptured or infected may be treated with:

• Injections. Your doctor may inject an inflamed, but uninfected, epidermoid cyst with a corticosteroid or triamcinolone acetonide (Kenalog) to help reduce inflammation.
• Incision and drainage. In this procedure, your doctor makes a small cut in the cyst and expresses the contents. Although incision and drainage is relatively quick and easy, cysts often recur after this treatment.
• Total excision. This surgical technique removes the entire cyst and so prevents recurrence. Excision is most effective when the cyst isn't inflamed. Your doctor may recommend first treating the inflammation with antibiotics, steroids, or incision and drainage and then waiting to perform excision for four to six weeks after inflammation resolves. Total excision requires sutures. Your doctor will remove sutures in your face within a week or so of total cyst excision, and will remove sutures elsewhere in your body within one to two weeks.
• Minimal excision. Some doctors prefer this technique because it removes the whole cyst wall but causes minimal, if any, scarring. During the procedure, your doctor makes a tiny incision in the cyst, expresses the contents, and then removes the cyst wall through the incision. The small wound is usually left to heal naturally.
• Lasers. To minimize scarring, your doctor may use a carbon dioxide laser to vaporize an epidermoid cyst on your face or other sensitive area.

Prevention

·         There's no way to stop epidermoid cysts from forming, but avoiding excessive sun exposure and using oil-free skin care products can help prevent milia. To prevent scarring and infection, don't try to squeeze cysts yourself.


rreferences

1. Epidermal cysts. The Merck Manuals: The Merck Manual for Healthcare Professionals. http://www.merck.com/mmpe/sec10/ch127/ch127c.html. Accessed March 2, 2011.
2. Goldstein BG, et al. Overview of benign lesions of the skin. http://www.uptodate.com/home/index.html. Accessed Feb. 18, 2011.
3. Penneys NS, et al. Common benign cutaneous growths: Seborrheic keratoses, cherry hemangiomas, and epidermoid cysts. American Academy of Dermatology. http://www.aad.org/education/students/benign_cutan_growths.htm. Accessed March 2, 2011.
4. Thomas VD, et al. Benign epithelial tumors, hamartomas, and hyperplasias. In Wolff K, et al. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, N.Y.: The McGraw-Hill Companies; 2008. http://www.accessmedicine.com/content.aspx?aID=2981819. Accessed March 3, 2011.
5. Habif TP. Benign skin tumors. In: Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. Edinburgh, U.K.; New York, N.Y.: Mosby Elsevier; 2010. http://www.mdconsult.com/books/about.do?about=true&eid=4-u1.0-B978-0-7234-3541-9..X0001-6--TOP&isbn=978-0-7234-3541-9&uniqId=230100505-57. Accessed March 3, 2011.