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Cutaneous cysts are closed, sac-like, or encapsulated structures that may be filled with air, liquid, or semi-solid material, and are generally benign. Many types of cysts can occur in almost any place throughout the body and can form in all ages. They are seen as slow-growing and painless lumps underneath the skin. However, some cysts may be painful if they are particularly large. Treatment depends on several factors including the type of cyst, location, size, and the degree of discomfort caused. Large, symptomatic cysts can be removed surgically, while smaller, asymptomatic cysts can be drained or aspirated. Here, we present the case of a 12-year-old male with a pus-filled cystic mass on his first left toe and discuss surgical management and follow-up.
Infected cyst, cutaneous cyst, epidermal cyst.
This patient underwent an incision and drainage of a small, pus-filled cystic mass located on the plantar aspect of his first left toe. This technique is a curative procedure that allowed the pus originally contained within the cyst to drain, thereby eliminating the cystic mass. The original plan was to create a Z-incision to relieve skin tension and to increase the exposure of the cystic mass. The surgeon was able to drain and expel most of the pus from the infected cyst through a single linear incision. By avoiding a bigger incision, the patient will recover more quickly with a better cosmetic outcome.
An adolescent male was found to have a cystic mass on the plantar aspect of his first left toe. This mass caused the patient discomfort during walking or standing. The patient denied any history of fever, chills, or drainage from the mass.
Physical examination is an important aspect of detecting cutaneous cysts. Preoperatively, the surgeon palpated what seemed like a solid nodular mass just beneath the skin on the plantar aspect of the first left toe. The overlying skin was intact without any signs of trauma, rashes, or lesions.
Imaging is not usually warranted for the diagnosis of cutaneous cysts. However, an ultrasound can be performed to determine the extent and dimensions of the cyst. On all imaging modalities, cysts generally appear as well-circumscribed masses arising within, or just deep into the skin.1
Cutaneous cysts are closed, sac-like, or encapsulated structures that may be filled with air, liquid, or semi-solid material, and are generally benign. The diagnosis of cutaneous cysts is made based on the nature of the epithelial lining and the cyst content.2 The most common cutaneous cysts such as milia and epidermoid cysts are lined by stratified squamous epithelium. Some cysts, including mucocele and digital myxoid cyst, are not lined by an epithelium. In this case, we are unsure of the epithelial lining since no biopsy was performed to determine this. The presence of pus in the cyst indicates an infectious etiology. The initial treatment of choice of a cyst, especially an infected cyst such as this case, would be an incision and drainage. There is a possibility that the cyst will recur if it has an epithelial lining. To prevent this recurrence, the capsule of the cyst must be removed.
Minor cysts that present without irritating symptoms can be left untreated with watchful waiting. Steroid injections can be used initially to decrease inflammation in the cyst, making it less prevalent and painful. However, it is not indicated in this case because the cyst itself was already infected.
Surgical treatment is indicated when the cyst begins to cause discomfort, infection, inflammation, or for cosmetic purposes. In this case, the cyst required an incision and drainage because it was already infected. If left untreated, the infected cyst may become larger and cause increasing discomfort. Furthermore, an untreated infected cyst can infect the surrounding areas causing cellulitis or osteomyelitis. Infected cysts may even infect the bloodstream.
There are no absolute contraindications to the incision and drainage of an infected cyst. Caution is advised in patients with bleeding disorders, taking anticoagulants, or with thrombocytopenia. Depending on the type of cyst, the capsule can be removed at a later time, which requires patient follow-up.
This presentation of a cystic mass was unexpected, as the preoperative assessment had suggested a solid mass. The initial surgical plan was to simply remove and excise this seemingly solid mass. Upon discovering that the mass was cystic and pus-filled, the surgical plan changed to an incision and drainage. An incision and drainage technique constitutes the primary therapy for the management of cutaneous infected cysts. Most cutaneous abscesses are appropriate for incision and drainage when they are greater than 5 mm in diameter and are in an accessible location.3
Transient bacteremia can occur during an incision and drainage procedure. Therefore, patients may require preoperative treatment with antibiotics. Antibiotic treatment is usually recommended for patients with any of the following: single abscess ≥ 2 cm, multiple lesions, extensive surrounding cellulitis, associated immunosuppression, systemic signs of toxicity (e.g. fever > 100.5°F/38°C, hypotension, or sustained tachycardia), those with an indwelling medical device (e.g. prosthetic joint) or in patients who had an inadequate clinical response to incision and drainage alone.4 Healthy patients, such as in this case, who have small abscesses (e.g. < 2 cm) with no local signs of cellulitis or systemic signs of bacteremia can forego antibiotic therapy. Furthermore, subsequent treatment with antibiotics is not usually necessary after a successful incision and drainage procedure in a healthy patient.
The postsurgical care from a successful incision and drainage of a simple abscess consists of allowing the incision to openly drain the wound. This will allow the body’s host defenses to clear the infection without exposing the patient to the potential adverse effects of antibiotic therapy. As shown in the video, the wound was covered with a sterile, non-adherent dressing. Patients should expect some continued drainage from the packed wound. On subsequent visits for wound care, packing material should be removed to permit healing by secondary intention.3
No special equipment was used.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Gaillard F, Ashraf A. Epidermal inclusion cyst. Radiopaedia. 2020. Available from: https://radiopaedia.org/articles/epidermal-inclusion-cyst?lang=us. Accessed April 14, 2021.
- Goldstein BG, Goldstein AO. Overview of benign lesions of the skin. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc; 2021. Available at: www.uptodate.com. Accessed April 14, 2021.
- Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess incision and drainage. NEJM. 2007; 357(19). doi:10.1056/nejmvcm071319.
- Spelman D, Baddour LM. Cellulitis and skin abscess in adults: treatment. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc; 2021. Available at: www.uptodate.com. Accessed April 14, 2021.
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So this is a 12-year-old male with a mass here in the... in the big toe, underneath. Uh, it seems like solid tissue, we'll see later. So I drew out an incision, which is like what we call a Z- a Z-plasty, a Z-incision. This should lessen out the tension because this area would have a lot of movement when he walks. So when he moves, this will cause some problems if we just make a straight incision. So this incision is allow more exposure, more exposure for the mass to be removed easier, and to also create less tension when he, when he walks, using this. So I'll, I'll show you the incision later.
Now, if you want to do a local block here, uh, the nerves go through the lateral parts of the, of the big toe, here and here. So, I'll have some local anesthesia here, inject here and here until you go to the bone. So you inject straight down, perpendicular to this bone, until you hit the bone, and then you retract it a bit. Okay? So here, this is my incision site. So I go straight down to the bone. There, until you hit it, then you\retract a bit. You could aspirate, I'm not inside a vessel. I try injecting slowly. There we go. We're hitting the nerve right there. So I normally infiltrate around- 1- 1.5 to 2cc. And I go to the other side. I go straight down on the other side to the bone again. There, once you hit the bone, Retract a bit. Aspirate. We're not inside a vessel. You could again, infiltrate. It might sting a bit. I insert around another 1cc. Then I just apply pressure to the area. Massage it a bit so that the local anesthesia could, could be absorbed by the tissues and you'll have its effect after a few seconds. I would also after, after I wait for these blocks, this digital block, to work, I'll be able to insert another needle here, to anesthetize the area. But this will be less painful. So, best to do the blocks first. and then local- local anesthesia, please? I'll infiltrate superficially. He should have less pain now. Here we go. Okay. I don't see, I don't see him reacting. So it feels like he should be okay. As a general rule, they normally avoid using, um, epinephrine with Lidocaine with surgery on the digital, on the digits, just to avoid any problems.
So I'll start my incision. As I mentioned, I'm doing a Z, Z-type incision. As you can see, it's like a inverted Z here. I'll show you why later. Sometimes you could also bring it down a bit here to expose more. Or here. But let's see, sometimes we could do, you could do just with this type of incision. So, I'm starting. Normally, you could use a smaller blade, like a blade 15, but this is okay. So make a small incision here. Don't go too deep, so you don't hit the mass. Some Lidocaine's coming out, some pus.
Well, I'm already squeezing it out actually. It's not solid, it's, there's some pus, and that's flat. There, you can see there. So it seems like an infected, infected cyst or- so it seems like an infected, infected cyst. So sometimes, preoperatively you might think it's a mass, a solid mass. Now after, after this linear incision, you can see some, a lot of pus came out. Maybe we don't want it, we don't need to do any further incision there. So I just try to insert this. There you can see more pus coming out. There. So sometimes it's good that I just made that first incision, and all the pus came out. So I will avoid making a bigger incision. So even just a small, small wound already drained out everything. And I just have to just flush the area, flush it out clean. And maybe just leave this, this wound to heal by secondary healing. So that we allow also some, some more discharge to come out in the next few days. So it's now flat. I don't see any... So I don't think it's, it's worth to continue the incision to make it a bigger one because I already drained out everything. So I just make this into a- just to flush it out. Clean the area inside with NSS. You could use also hydrogen peroxide, if you want. So I just clean the area. Then you just press... And we should be done. I just put a dressing over it and allow this wound to close in the next few days.
So I normally don't, I normally don't put a suture anywhere here- because- we want to drain it out. So we're done. I just drained out the fluid. It seemed like an infected cyst.