Cysts

A cyst is a closed sac or pocket of fluid, semi-fluid or solid material inside the body. It has a definite wall. A true cyst is lined by epithelium (special surface or lining cells).

Cysts can occur almost anywhere in the body. However, if you are aware of a cyst it is usually a cyst related to the skin. For women cysts in the breast are also common and can be felt as a breast lump.

Cysts may be something your are born with or they can develop later in life due to blockages of draining ducts or abnormalities of tissues.

Skin cysts are usually benign but rarely it possible for them to be cancerous.

There are different types of skin cysts. These vary with the structures which they develop from. Typically, they arise from the hair follicles or glands like sweat glands. For practical purposes it makes little difference as they tend to behave in the same way and they are treated in a similar way.

Epidermal cysts are the most common skin cysts and are filled with dead skin cells (keratinocytes). Sebaceous cysts contain sebum and pilar cysts come from hair follicles. There are many more.

Most skin cysts are benign and generally harmless. However, they can be uncomfortable or inconveniently placed where they get in the way. More troublesome is where they become infected in which case they usually swell, are tender and are red. These may then settle, or the infection may become worse. If the infection progresses there may be a build-up of pus in the cyst in which case it is now called an abscess. Abscesses are very tender and painful. If left untreated they will usually lead to the cyst breaking and discharging

Skin cysts are very rarely cancerous. Cysts at other sites in the body are more concerning for being cancerous.

Cysts may remain small and cause not problems. There are several reasons to have a cyst removed and frequently it will be for a combination of reasons.

Confirm the diagnosis of a cyst.

If the diagnosis of a cyst is uncertain the a cyst may be removed to confirm that they are simply a cyst and not something more serious such as a tumour.

Prevent the cyst enlarging.

A cyst may be removed to prevent it enlarging which may then result in it becoming inconvenient or unsightly.

If the cyst becomes inconvenient.

A cyst may get in the way and be uncomfortable. Cysts in the scalp may interfere with combing hair.

Unsightly for cosmetic reasons.

Cyst are often visible and unsightly they may cause embarrassment and other people may comment on them. Their appearance is a very common reason for people to seek to have a cyst remove.

To prevent infection.

Infection of the cyst can be very painful and inconvenient especially if they progress to form an abscess. Removing a cyst before it becomes infected is preferable.

Surgical removal of a skin cyst will usually take between 10 and 30 minutes depending on its size and where it is.

The area around the cyst is numbed with an injection of local anaesthetic. Local anaesthetic injections sting and are uncomfortable. Some parts of the body are more tender than others. Most people find it is something they can cope with and that it is worth it to have the cyst removed. Once the local takes effect usually with a couple of minutes the area becomes numb and you will feel no pain. You may be aware of pulling and tugging in the area during the procedure.

People vary in how uncomfortable they find small operations. Many people will require no analgesia. However, if you are finding it painful then paracetamol and or ibuprofen will be sufficient for most people. It is sensible to have analgesia in the house in case you need it.

It is worth remembering that it is easier to keep pain away than it is to get rid of pain once you are in pain.

If you are too active in the days after surgery you may cause bleeding. This may result in the wound bleeding or a build-up of blood under the skin called a haematoma. A haematoma may require more surgery to remove it. A haematoma may affect the appearance of the end result. Stressing the wound may cause stitches to break or pull out resulting in the wound opening up (dehiscence). You should avoid exercise for 14 days. Between 14 days and a month gentle exercise is fine. After a month more vigorous exercise can be started but the wound is not fully healed for another month. A healed wound reaches full strength after 2 months. The scar tissue will then mature over several more weeks or months.

In general a wound reaches about half the strength of normal skin after a month and 85% of normal skin by two months. This is as strong as the healed wound will achieve. A scar is never as strong as the original skin. After the wound edges are fully joined together the scar undergoes a process of maturation.

When skin is cut it will almost always heal to leave a scar. Scar is the repair tissue of the body. There are many factors that will affect the visibility of a scar. Many of these are genetic factors that can not be changed. Some people will make bad or visible scars because that is how they heal. Other people with a similar wound make an almost invisible scar.

Undesirable scars may stretch so they are wide. Some scars may become raised red and lumpy in what is called a hypertrophic scar. These scars may be itchy or painful.

Keloid scars are scars that grow out from the original wound as a lump. These lumps may be red raised and can grow to a large size compare with the original wound. Some people appear genetically predisposed to make keloid scars. They are more common down the front of the chest, shoulders and ear lobes but can occur anywhere. Certain racial groups, particularly black skin, are more susceptible.

For management of keloid scars please see the section on keloids.

All surgery carries risks. The main risks are:

Bleeding and haematoma

Wounds can bleed after surgery.  A build-up of blood under the skin is called a haematoma. A haematoma may require more surgery to remove it. A haematoma may affect the appearance of the end result

Infection

A surgical wound can become infected. With surgery on uninfected clean skin this unlikely with less than 1 out of every 25 wounds becoming infected. These will usually settle with antibiotics but it is possible for the infection to form an abscess and then discharge through the wound or require surgery to drain it. Infection progressing to sepsis which is potentially life threatening is very rare in healthy people having skin surgery.

Wound breakdown and delayed healing

Wounds can open up or breakdown. This is most likely to happen if the wound is stressed in the early stages of healing or if it becomes infected. The wound will then usually heal ‘from the bottom up’ and this may take several weeks. The result is usually a wide scar that may be depressed. Some people may want further surgery to try and improve the appearance.

Poor scarring

Most people find the scar from surgery acceptable and worth the benefits of the surgery. The appearance of scar varies a lot from one person to another. Some people may very good nearly invisible scars when others with a similar wound may make an unsightly poor scar. Poorly planned surgery and complications like infection may well lead to poor scars. For other people a genetic tendency to make hypertrophic or keloid scars may result in a poor appearance of a scar. The section on the website about scarring has more details on poor scars.

Deformity

When a large cysts is removed from under the skin it may result in a depression in the skin. The cyst having pushed away the normal fat and tissues under the skin. Once the cyst is removed there is an inevitable depression in the skin. These usually improve with time but to a degree are permanent.

Recurrence of the cyst

If a cyst is completely removed it is unlikely to recur. If part of the cyst is left behind when it is removed surgically then recurrence is much more likely.

If you have made one cyst you are more likely to make more cysts in the future.

Risks of not having a cyst assessed or treated

There are risks of treatment but there are also risks of not having treatment. An untreated cyst make enlarge and become more difficult to treat. A cyst can become infected which can be quite unpleasant and inconvenient.  A ‘cyst’ that has not be assessed may turn out to be more serious than a simple cyst.

Standard medical practice is to send skin abnormalities and ‘lumps’ that are removed from the body to the laboratory for analysis called histopathology.

For a typical epidermal type cyst the value of doing this can be discussed. Careful examination of a removed cyst by an experienced surgeon may be sufficient to make a confident diagnosis of a benign cyst. If there is any doubt the ‘cyst’ would be sent for analysis. It is reasonable to discuss the need for sending a cyst for analysis with your surgeon. The advantage of not sending it is a saving of the cost of having it analysed.

No treatment

Not all cysts need to be removed. Small cysts that are not growing or causing any problems can be left alone. If your cyst is not removed you should keep it under observation. If it changes in the future you should seek medical advice.

Surgical Excision (removal)

Surgical excision is the main treatment option. This enables confirmation of the diagnosis and gets rid of the cyst.

Surgical Drainage of a cyst

Draining the contents of a cysts is an option. However, as it does not remove the wall of the cyst the cyst is likely to come back.

The time when drainage is the best treatment is when the cyst is infected. The best approach is to drain the contents which will enable the body to get rid of the infection. Once the infections has gone if there is a residual cyst it may be sensible to remove it to prevent it growing back.

Investigation of the cyst

Under some circumstances it may be necessary to investigate a cyst further with scans. It may be necessary to confirm the lump is a cyst and not a tumour. There may concerns that a cysts is resulting from a problem deeper in the body.

If you contact my office they will be able to arrange a consultation with me. This is usually best in person, however, sometimes, it may be possible to do it over the internet.