Differential Diagnosis of Epidermal and Trichilemmal Cysts

Lipoma: Difficult to differentiate clinically; more firm, lobulated; no cheesy material extrudes on incision; removal is by complete excision or by liposuction; clinically similar to hibernoma.

Dermoid cyst: Clinically similar; can also be found internally; usually a solitary skin tumor; histologically, contains hairs, eccrine glands, and sebaceous glands.

Mucous cysts (Fig 3.2.-6): Translucent pea-sized or smaller lesions on the lips, treated by cutting off top of the lesion and carefully lightly cauterizing the base with a silver nitrate stick or light electrosurgery.

Epidermal Fungs

Figure 32-6. Cysts of the skin. Mucous cyst on lower lip. (Texas Pharmacal)

Synovial cysts (mytoid cysts) of the skin (Fig.32-7): Globoid, translucent, pea-sized swellings around the joints of fingers and toes.

Figure 32-7. Cysts of the skin. Synovial cyst on finger. (Texas Pharmacal)

Treatment of Epidermal and Trichilemmal Cysts

Several methods can be used with success. The choice depends on the ability of the operator and the site and the number of cysts. Cysts can regrow after even the best surgical care, because of incomplete removal of the sac.

1. A single 3-cm cyst on the back should be removed by surgical excision and suturing. This can be done in two ways: either by incising the skin and skillfully removing the intact cyst sac or by cutting straight into the sac with a small incision, shelling out the evacuated lining by applying strong pressure to the sides of the incision, and suturing the skin. The latter procedure is simpler, requires a smaller incision, and is quite successful.

2. A patient with several cysts in the scalp can be treated in another simple way. A 3- to 4-mm incision can be made directly over and into the cyst. The cheesy, foul-smelling contents can be evacuated by pressure and the use of a small curette. The sac can then be popped out of the hole with very firm pressure, or the sac can be grasped with a small hemostat and pulled out of the opening. No suturing or only a single suture is necessary. The resulting scar will be imperceptible in a short time.

3. If, during incision by any technique, a solid tumor is found instead of a cyst, the lesion should be excised completely and the material studied histologically. This diagnostic error is common because of the clinical similarity of cysts, lipomas, and other related tumors.

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