Incision & Drainage of an Infected Cyst – Part 1 of 3

This patient has been seeing Dr Rebish recently because he has had this cyst on his neck which has recently become inflamed and “infected”. I put “infected” in quotes, because technically this is not an infection: When an epidermoid cyst ruptures, it creates a vigorous foreign body inflammatory response – this skin becomes warm, tender, painful, and swells, simulating an abscess. Incision and Drainage (I & D), will confirm the diagnosis of inflamed cyst, when the smelly, cheesy material is evacuated, and this often leads to rapid resolution of symptoms. These episodes are often misdiagnosed as “infection” of the cyst, but cultures are usually negative and antibiotic treatments is not required. Intralesional steroids can hasten the resolution of symptoms as well.

All this being said, we often prescribe antibiotics- it’s hard not to when you see something so red and inflamed and painful.. it seems almost cruel not to! Also, we as dermatologists, will just call the cyst infected, or call it an abscess. It’s more difficult to explain to patients why we would not call an area that looks angry and red and is painful non-infected. However, I felt I needed to clarify all of this in detail here, for medical education purposes!

Anyway, Dr Rebish had been injecting the area with steroids to decrease the inflammation but he had an appointment with me to finally excise the area because he was fed up with it. When I saw it, we prepared for an excision, but it actually turned into an I & D, the cyst was completely broken down because it had ruptured. After evacuating the area, there was a pretty large empty space which I packed with iodophorm gauze which may decrease the chance for continued inflammation or minimize chance of infection. I saw him a few days later because the area will still draining but was less swollen and less painful. At this point, I decided to pull out the rest of the gauze and just let it heal without it. I feel that the iodophorm gauze was not helping and perhaps worsening the situation. I wish I took a video of this, but I was in a hurry seeing him between patients, so I didn’t have the time! Sorry about that!
This may be a more disturbing video for many of you, and I will admit it was difficult for me to do. I don’t like draining abscesses. They are ooey and gooey and often smell putrid, and you can see me carefully and gently squeeze and wipe away often. We are wearing splash screens. If this stuff gets in your hair or on your skin it can ruin your day. Especially when it gets in your hair, b/c it stays with you until the next time you take a shower. Luckily none of us get dirty, but this was my last patient before lunch and I had to go home and lie down for an hour or so to recover from this. Has to be done, but no. fun. The PATIENT on the other hand is lovely and I thank him for letting me treat him and film it for all of you to see.
At the end of this video, you can see that he was doing much better a couple of weeks after this procedure. No longer having pain or discomfort in the area, and in is minimally swollen and improving every day. We will continue to follow his progress and let you know if anything changes!

Please look out for part 2 and 3 which I will release later today!

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This video may contain dermatologic surgical and/or procedural content. The content seen in this video is provided only for medical education purposes and is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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