What are epidermal inclusion cysts. How do they form. What are the common symptoms. What treatment options are available. When should you seek medical attention for an epidermal inclusion cyst. How can epidermal inclusion cysts be prevented. What are the potential complications of untreated epidermal inclusion cysts.

Understanding Epidermal Inclusion Cysts: An Overview

Epidermal inclusion cysts, often mistakenly referred to as sebaceous cysts, are the most common type of cutaneous cysts. These benign growths can appear anywhere on the body and typically present as small, round nodules just beneath the skin’s surface. While they are generally harmless, they can sometimes become inflamed or infected, causing discomfort and cosmetic concerns.

These cysts are filled with keratin, a protein that’s a major component of skin, hair, and nails. The keratin often has a characteristic “cheesy” appearance when the cyst is opened. It’s important to note that despite their colloquial name, these cysts do not contain sebum and do not originate from sebaceous glands.

Key Characteristics of Epidermal Inclusion Cysts

• Size ranges from a few millimeters to several centimeters in diameter
• Usually freely moveable under the skin
• Often have a visible central punctum (small opening)
• Can remain stable or gradually enlarge over time
• May become inflamed or infected, causing pain and redness

The Etiology and Epidemiology of Epidermal Inclusion Cysts

Understanding the underlying causes and prevalence of epidermal inclusion cysts can help in their management and prevention. These cysts are typically sporadic, meaning they occur randomly without a clear genetic link in most cases.

What causes epidermal inclusion cysts?

Epidermal inclusion cysts primarily arise from the infundibulum of hair follicles. When the follicular orifice becomes plugged, it can lead to cyst formation. Secondary cysts can also develop due to the implantation of follicular epithelium in the dermis, often as a result of trauma or comedone formation.

Several factors can contribute to the development of these cysts:

• Inflammation of hair follicles
• Acne vulgaris
• Chronic sun damage to the skin
• Certain medications (e.g., BRAF inhibitors like imiquimod and cyclosporine)
• Human papillomavirus infection
• Chronic ultraviolet light exposure

Who is most likely to develop epidermal inclusion cysts?

Epidemiological data provides insights into the populations most affected by these cysts:

• More common in men than women (2:1 ratio)
• Peak incidence in individuals aged 20 to 40 years
• Higher prevalence in elderly patients with chronic sun-damaged skin
• Increased frequency in patients with acne vulgaris
• Can occur in neonates as milia

Pathophysiology: The Mechanism Behind Cyst Formation

The formation of epidermal inclusion cysts involves a specific sequence of events at the cellular level. Understanding this process can provide valuable insights into prevention and treatment strategies.

How do epidermal inclusion cysts develop?

The pathophysiology of these cysts can be broken down into several key steps:

1. Plugging of the follicular orifice
2. Accumulation of keratin within the blocked follicle
3. Expansion of the follicle due to continued keratin production
4. Formation of a cyst lined with stratified squamous epithelium
5. Possible communication with the skin surface through a small orifice (central punctum)

In cases of secondary cyst formation, trauma or other factors can lead to the implantation of follicular epithelium in the dermis, initiating cyst development in atypical locations.

Clinical Presentation and Diagnosis of Epidermal Inclusion Cysts

Recognizing the typical presentation of epidermal inclusion cysts is crucial for accurate diagnosis and appropriate management. While these cysts can occur anywhere on the body, they are most commonly found on the face, scalp, neck, back, and scrotum.

What are the common symptoms of epidermal inclusion cysts?

Patients with epidermal inclusion cysts may experience the following symptoms:

• A small, round bump under the skin
• Slow growth of the cyst over time
• A visible central punctum (small black dot on the surface)
• Pain or tenderness if the cyst becomes inflamed or infected
• Redness and warmth around the cyst in cases of infection
• Drainage of foul-smelling, cheese-like material if the cyst ruptures

How are epidermal inclusion cysts diagnosed?

Diagnosis of epidermal inclusion cysts is typically based on clinical examination. Healthcare providers will assess the following:

• Appearance and location of the cyst
• Presence of a central punctum
• Mobility of the cyst under the skin
• Signs of inflammation or infection
• Patient’s medical history, including previous cysts or skin conditions

In some cases, additional diagnostic procedures may be necessary:

• Ultrasound imaging to confirm the cystic nature of the lesion
• Biopsy for histopathological examination, especially if malignancy is suspected
• Genetic testing if a hereditary syndrome is suspected (e.g., Gardner syndrome)

Treatment Options for Epidermal Inclusion Cysts

The management of epidermal inclusion cysts depends on various factors, including the size of the cyst, its location, and whether it’s causing symptoms or cosmetic concerns. Treatment options range from conservative approaches to surgical interventions.

What are the non-surgical treatment options for epidermal inclusion cysts?

For asymptomatic or minimally bothersome cysts, conservative management may be appropriate:

• Observation: Small, asymptomatic cysts may not require treatment
• Warm compresses: Can help reduce inflammation and promote drainage
• Intralesional corticosteroid injection: May help reduce inflammation in symptomatic cysts
• Incision and drainage: For infected cysts, though recurrence is common

When is surgical removal of epidermal inclusion cysts necessary?

Surgical excision is often the definitive treatment for epidermal inclusion cysts, especially in the following situations:

• Large or rapidly growing cysts
• Cysts in cosmetically sensitive areas
• Recurrent or frequently inflamed cysts
• Cysts causing functional impairment
• Suspicion of malignancy

Surgical techniques for cyst removal include:

1. Conventional excision: Complete removal of the cyst and its wall
2. Minimal excision technique: Smaller incision with expression of cyst contents
3. Punch biopsy excision: For smaller cysts

Potential Complications and Prognosis

While epidermal inclusion cysts are generally benign, they can lead to complications if left untreated or improperly managed. Understanding these potential issues is crucial for patients and healthcare providers alike.

What complications can arise from untreated epidermal inclusion cysts?

Potential complications include:

• Infection: Can lead to abscess formation and systemic symptoms
• Rupture: May cause inflammation and scarring
• Scarring: Particularly if the cyst becomes infected or ruptures
• Functional impairment: Large cysts may interfere with movement or daily activities
• Psychological distress: Due to cosmetic concerns or recurrent symptoms

Is there a risk of malignant transformation in epidermal inclusion cysts?

While rare, malignant transformation of epidermal inclusion cysts has been reported. The risk is estimated to be less than 1%. Factors that may increase suspicion of malignancy include:

• Rapid growth or change in appearance
• Ulceration or bleeding
• Recurrence after complete excision
• Cysts larger than 5 cm in diameter

Any suspicious features warrant prompt evaluation and possible biopsy.

Prevention and Long-term Management

While it’s not always possible to prevent epidermal inclusion cysts, certain measures can help reduce their occurrence and manage existing cysts effectively.

How can the formation of epidermal inclusion cysts be prevented?

Prevention strategies focus on addressing known risk factors:

• Proper skincare: Regular cleansing to prevent follicular blockage
• Acne management: Effective treatment of acne vulgaris
• Sun protection: Reducing chronic sun damage to the skin
• Avoiding trauma: Minimizing skin injuries that could lead to cyst formation
• Early intervention: Addressing small cysts before they enlarge

What long-term management is required for individuals prone to epidermal inclusion cysts?

For individuals who frequently develop these cysts, long-term management may involve:

• Regular skin examinations: To detect new cysts early
• Prompt treatment of inflamed or infected cysts
• Consideration of prophylactic excision for recurrent cysts
• Genetic counseling: If a hereditary syndrome is suspected
• Lifestyle modifications: Such as avoiding excessive sun exposure

By implementing these preventive measures and maintaining vigilant long-term management, individuals can minimize the impact of epidermal inclusion cysts on their quality of life.

Special Considerations and Related Conditions

While most epidermal inclusion cysts are sporadic and benign, there are certain situations and related conditions that warrant special attention. Understanding these can help in providing comprehensive care and identifying potential underlying issues.

Are there any hereditary syndromes associated with epidermal inclusion cysts?

Yes, several hereditary syndromes can feature epidermal inclusion cysts as part of their clinical presentation:

• Gardner syndrome: An autosomal dominant condition characterized by multiple epidermoid cysts, osteomas, and colorectal polyps
• Favre-Racouchot syndrome: Also known as nodular elastosis with cysts and comedones, typically seen in sun-damaged skin
• Gorlin syndrome: Also called basal cell nevus syndrome, featuring multiple basal cell carcinomas and epidermoid cysts

In these cases, the presence of multiple or unusually located epidermal inclusion cysts may warrant further investigation for underlying genetic conditions.

How do epidermal inclusion cysts differ from other types of cysts?

It’s important to distinguish epidermal inclusion cysts from other types of cysts to ensure appropriate management:

• Pilar cysts: Originate from hair follicles and are most common on the scalp
• Dermoid cysts: Congenital cysts that may contain hair follicles and sweat glands
• Pilonidal cysts: Occur near the tailbone and can become infected
• Branchial cleft cysts: Congenital cysts found in the neck

Each type of cyst has unique characteristics and may require different management approaches.

What role does interprofessional care play in managing epidermal inclusion cysts?

Effective management of epidermal inclusion cysts often involves a collaborative approach:

• Primary care physicians: For initial evaluation and conservative management
• Dermatologists: For specialized skin assessment and treatment
• Plastic surgeons: For excision of cysts in cosmetically sensitive areas
• Pathologists: For histopathological examination of excised cysts
• Geneticists: In cases where hereditary syndromes are suspected

This interprofessional approach ensures comprehensive care, especially for complex cases or when underlying conditions are present.

In conclusion, epidermal inclusion cysts, while common and typically benign, require thoughtful evaluation and management. By understanding their etiology, presentation, and treatment options, healthcare providers can offer effective care tailored to each patient’s needs. For individuals affected by these cysts, awareness of prevention strategies and the importance of timely medical attention can help minimize complications and improve overall outcomes.

Epidermal Inclusion Cyst – StatPearls

Continuing Education Activity

Epidermal inclusion cysts are the most common cutaneous cysts and can occur anywhere on the body. These cysts typically present as fluctuant nodules under the surface of the skin, often with visible central puncta. These cysts often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. This activity reviews the evaluation and management of epidermal inclusion cysts and highlights the importance of an interprofessional approach to caring for affected patients.

Objectives:

• Identify the etiology of epidermal inclusion cysts.

• Describe the evaluation of epidermal inclusion cysts.

• Describe the treatment and management options available for epidermal inclusion cysts.

• Explain interprofessional team strategies for improving care coordination and communication to advance the management of epidermal inclusion cysts and improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Epidermal inclusion cysts are the most common cutaneous cysts. Numerous synonyms for epidermal inclusion cysts exist, including epidermoid cyst, epidermal cyst, infundibular cyst, inclusion cyst, and keratin cyst. These cysts can occur anywhere on the body, typically present as nodules directly underneath the patient’s skin, and often have a visible central punctum. They are usually freely moveable. The size of these cysts can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge over time. There are no reliable predictive factors to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. Infected and/or fluctuant cysts tend to be larger, erythematous, and more noticeable to the patient. Due to the inflammatory response, the cyst will often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. The center of epidermoid cysts almost always contains keratin and not sebum. This keratin often has a “cheesy” appearance. They also do not originate from sebaceous glands; therefore, epidermal inclusion cysts are not sebaceous cysts. The term “sebaceous” cyst should not be used when describing an “epidermoid” cyst. Unfortunately, in practice, the terms are often used interchangeably.[1]

Etiology

The majority of epidermoid cysts are sporadic. Epidermal inclusion cysts are extremely common, benign, not contagious, and can appear to resolve on their own. Without definitive treatment, they can reoccur. They often occur in areas where hair follicles have been inflamed and are usually common in conjunction with acne.[1][2][3]

Epidemiology

They are more common in men than women, with a ration of 2:1. They occur more frequently in patients in their 20s to 40s. Epidermal inclusion cysts by themselves are usually not genetically linked. They can be hereditary in rare syndromes such as Gardner syndrome, nodular elastosis with cysts and comedones (Favre-Racouchot syndrome), and basal cell nevus syndrome (Gorlin syndrome). Elderly patients with chronic sun-damaged skin areas have a higher likelihood of developing epidermoid cysts. Patients on BRAF inhibitors such as imiquimod and cyclosporine have a higher incidence of epidermoid cysts of the face. They often occur in areas where hair follicles have been inflamed or repeatedly irritated.  They are more frequent in patients with acne vulgaris. They can be seen during the neonatal period known as milia.[1]

Pathophysiology

The epidermal inclusion cyst can be primary or secondary. Primary epidermal cysts arise directly from the infundibulum of the hair follicle. Plugging of the follicular orifice allows for cyst formation. The cyst often communicates with the surface of the skin through a small orifice or visible central punctum. Patients suffering from acne vulgaris have a higher rate of hair follicle disruption and pore blockages leading to a higher rate of epidermal inclusion cyst formation from preexisting comedones. Secondary epidermoid cysts can arise after the implantation of the follicular epithelium in the dermis due to trauma or comedone formation. Epidermoid cysts are lined with stratified squamous epithelium with the accumulation of keratin in the core. Recently, Human papillomavirus and chronic ultraviolet light exposure have been seen to allow epidermal cysts to form.

Additionally, the epidermal inclusion cysts can occur in any area of the body. Most often, they are found on the face, scalp, neck, back, and scrotum. Inclusion cysts found in unusual numbers or locations like the extremities, trunk, or the back of the ears may be seen in the setting of Gardner syndrome. Gardner syndrome or familial adenomatous polyposis (FAP) with extracolonic manifestations is an autosomal dominant inherited disease due to a mutation in the APC gene on chromosome 5. The cardinal clinical feature is innumerable, widespread colonic polyps in conjunction with extracolonic lesions. In this disease process, the epidermal cysts will often appear before the onset of puberty and may even precede the onset of colonic polyposis.[1]

Histopathology

Epidermoid inclusion cysts can be confirmed by histologic examination. Epidermal inclusion cysts, more specifically, demonstrate the implantation of epidermal elements into the dermis layer of the skin. The cyst wall is usually derived from the infundibular portion of the hair follicle. Thus, the majority of epidermal inclusion cysts may be referred to as an infundibular cyst. However, a cyst’s wall can be derived from another etiology, explaining the interchangeable yet inaccurate use of the two names. The cystic cavity is filled with laminated keratinous material. Often, a granular layer is present that is filled with keratohyalin granules. In the event a cyst ruptures, a keratin granuloma can be seen during the examination. Infected cysts microscopically can show disruption of the cyst wall, acute inflammation or neutrophil invasion, or intense foreign body giant cell reaction. Approximately less than 1% of epidermal inclusion cysts have a malignant transformation to basal cell carcinoma or squamous cell carcinoma.[4][5]

History and Physical

The diagnosis of epidermoid cysts is usually clinical. It is based upon the clinical appearance of a discrete, freely moveable cyst, often with a visible central punctum. These cysts can occur anywhere on the body and typically present as nodules directly underneath the patient’s skin. The size of a cyst can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge. There is no predictive modality to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. An infected cyst tends to be large with increased erythema, and it is more noticeable to the patient.

Furthermore, if inflammation is present, it usually results in cyst rupture and extrusion of cyst contents into the surrounding cutaneous and/or subcutaneous tissues, which may or may not be the result of an active infection. The source of infection for cysts usually comes from normal skin flora organisms, such as Staphylococcus aureus and Staphylococcus epidermidis. Generally, epidermal inclusion cysts are asymptomatic until they rupture.

Evaluation

Epidermoid inclusion cysts are evaluated by the history and physical exam often in an office setting. The need for pathology or histological examination before the operating room is usually not warranted. Radiographic and laboratory exams, such as ultrasound studies, are unnecessary and not typically ordered unless the evaluation leads the practitioner to suspect a genetic condition.

Treatment / Management

Inflamed, uninfected epidermal inclusion cysts rarely resolve spontaneously without therapy or surgical intervention. Treatment is not emergent unless desired by the patient electively before an increase in symptom severity (pain and/or infection). Definitive treatment is the surgical excision of the cyst. Some sources describe an alternative, yet not definitive, minimally invasive therapy for treatment, such as injecting triamcinolone at the dosage of 10 mg/mL for the trunk and 3 mg/mL for the face. The injection should be introduced into the inflamed epidermoid cyst, and it can help resolve the inflammation, prevent infection, and potentially reduce the need for surgical incision and drainage.

The definitive treatment is the complete surgical excision of the cyst with its walls intact; this will prevent reoccurrence. Excision is best accomplished when the lesion is not acutely inflamed. During this period, the cyst wall is friable, and the planes of dissection are more difficult to appreciate, making complete excision less likely and increasing the rate of reoccurrence.

For surgical excision, a local anesthetic, such as lidocaine with epinephrine, can be used. The anesthetic should be injected around the cyst, with care to avoid direct injection into the cyst, injection into the central pore, or rupture of the cyst wall. A small incision is made with a #11 blade on the skin overlying the cyst. The cyst contents are then expressed by exerting lateral pressure on either side of the cyst. With this technique, the cyst wall is often freed from the adjacent tissues and can be completely extracted through the small incision. The minimal incision surgical option provides better cosmetic results than the standard excision technique. Maintaining the incision within the minimal skin tension lines is important for cosmetic results. Reoccurrence rates from 1% to 8% have been shown with the minimal incision technique. A multiple layer subcuticular closure with an additional epidermal closure will yield better cosmetic outcomes.[6]

An alternate surgical option is to utilize a 4 mm punch biopsy with the expulsion of the intact cyst through the defect created in mass. Regardless of the option chosen, removal of the entire cystic wall is paramount to decrease reoccurrence.

In the event of a fluctuant lesion, incision and drainage are often needed with the mechanical destruction of intracavitary loculations. The presence of surrounding cellulitis may necessitate the use of oral antibiotic therapy. Empiric antibiotic therapy can be done with oral agents active against methicillin-sensitive S aureus or oral agents active against methicillin-resistant S aureus in areas of high prevalence. For patients who wish to have a more conservative treatment in the setting of acute infection, the cyst can be drained, and the patient started on oral antibiotics with a plan of surgical excision of remaining contents at a later date for definitive management. This is recommended due to a higher likelihood of reoccurrence without definitive surgical management.[4]

Differential Diagnosis

Depending on the anatomical area of the suspected epidermoid inclusion cysts, the differential diagnosis includes pilar cyst, lipoma, abscess, neuroma, benign growths, skin carcinomas, metastatic cutaneous lesions, pilomatrixoma, ganglion cyst, neurofibroma, dermoid cyst, brachial cleft cyst, pilonidal cyst, calcinosis cutis, pachyonychia congenita, steatocystoma simplex, and steatocystoma multiplex.

Prognosis

Epidermal inclusion cysts have an excellent prognosis after complete excision of all contents and the cystic wall.

Complications

Complications of epidermal inclusion cysts before definitive management can occur due to rupture and may result in symptoms such as erythema, pain, swelling, localized cellulitis. The main complication seen in clinical practice is reoccurrence due to incomplete excision. Any time surgery is done, there is a small inherent risk of complications. Complications of epidermal inclusion cyst excisions may include but are not limited to infection, bleeding, damage to surrounding structures and tissues, scarring, and wound dehiscence. There is a risk of the cyst reoccurring if the capsule is not completely excised during the surgical procedure.

Pearls and Other Issues

Differential diagnosis of epidermal inclusion cysts also include lipomas, neuromas, benign cutaneous growths, metastatic skin lesions, squamous cell carcinoma of the skin, basal cell carcinoma of the skin.

Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach to patient care can help achieve the best possible outcomes. Cutaneous lesions and cysts are often found by a primary care provider or the emergency room provider on the initial presentation. The primary care provider or emergency department provider will often identify an epidermoid inclusion cyst or other cutaneous lesions. Given the provider’s comfort level, they will then attempt to drain or remove the cutaneous lesion in the office. Often, this lesion turns out to be an epidermal inclusion cyst during the procedure, and there is not a complete excision of the cyst capsule. This incomplete removal can lead to complications such as infection, localized pain, and recurrence.

Additionally, the providers might order imaging of the lesion, such as an ultrasound, to further evaluate the lesion. If better communication can take place between healthcare providers, they could refer the patient to general surgery before any intervention. The surgeon may then offer definitive operative management and complete removal of the cyst capsule. Seeing a surgeon early in the care of a prospective epidermal cyst may also lead to a decrease in unnecessary imaging, which can also contribute to decreasing the overall cost of healthcare. Nurses should instruct patients about postoperative care and notify the surgeon if there are complications. This, in turn, provides the patient with a decreased chance of complications. From an overall healthcare system perspective, early referral and definitive treatment by a general surgeon for epidermoid inclusion cysts would lead to a single procedure for the patient, a higher level of patient satisfaction, decreased overall healthcare costs, and better patient outcomes.

Figure

Epidermal Cyst. Contributed by DermNetNZ

References

1.

Zito PM, Scharf R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 29, 2020. Epidermoid Cyst. [PubMed: 29763149]

2.

Boussemart L, Routier E, Mateus C, Opletalova K, Sebille G, Kamsu-Kom N, Thomas M, Vagner S, Favre M, Tomasic G, Wechsler J, Lacroix L, Robert C. Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: a study of 42 patients. Ann Oncol. 2013 Jun;24(6):1691-7. [PubMed: 23406731]

3.

Urabe K, Xia J, Masuda T, Moroi Y, Furue M, Matsumoto T. Pilomatricoma-like changes in the epidermoid cysts of Gardner syndrome with an APC gene mutation. J Dermatol. 2004 Mar;31(3):255-7. [PubMed: 15187352]

4.

Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002 Apr 01;65(7):1409-12, 1417-8, 1420. [PubMed: 11996426]

5.

Apollos JR, Ekatah GE, Ng GS, McFadyen AK, Whitelaw SC. Routine histological examination of epidermoid cysts; to send or not to send? Ann Med Surg (Lond). 2017 Jan;13:24-28. [PMC free article: PMC5198733] [PubMed: 28053700]

6.

Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: a prospective, randomized study. Dermatol Surg. 2006 Apr;32(4):520-5. [PubMed: 16681659]

Epidermal Inclusion Cyst – StatPearls

Continuing Education Activity

Epidermal inclusion cysts are the most common cutaneous cysts and can occur anywhere on the body. These cysts typically present as fluctuant nodules under the surface of the skin, often with visible central puncta. These cysts often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. This activity reviews the evaluation and management of epidermal inclusion cysts and highlights the importance of an interprofessional approach to caring for affected patients.

Objectives:

• Identify the etiology of epidermal inclusion cysts.

• Describe the evaluation of epidermal inclusion cysts.

• Describe the treatment and management options available for epidermal inclusion cysts.

• Explain interprofessional team strategies for improving care coordination and communication to advance the management of epidermal inclusion cysts and improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Epidermal inclusion cysts are the most common cutaneous cysts. Numerous synonyms for epidermal inclusion cysts exist, including epidermoid cyst, epidermal cyst, infundibular cyst, inclusion cyst, and keratin cyst. These cysts can occur anywhere on the body, typically present as nodules directly underneath the patient’s skin, and often have a visible central punctum. They are usually freely moveable. The size of these cysts can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge over time. There are no reliable predictive factors to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. Infected and/or fluctuant cysts tend to be larger, erythematous, and more noticeable to the patient. Due to the inflammatory response, the cyst will often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. The center of epidermoid cysts almost always contains keratin and not sebum. This keratin often has a “cheesy” appearance. They also do not originate from sebaceous glands; therefore, epidermal inclusion cysts are not sebaceous cysts. The term “sebaceous” cyst should not be used when describing an “epidermoid” cyst. Unfortunately, in practice, the terms are often used interchangeably.[1]

Etiology

The majority of epidermoid cysts are sporadic. Epidermal inclusion cysts are extremely common, benign, not contagious, and can appear to resolve on their own. Without definitive treatment, they can reoccur. They often occur in areas where hair follicles have been inflamed and are usually common in conjunction with acne.[1][2][3]

Epidemiology

They are more common in men than women, with a ration of 2:1. They occur more frequently in patients in their 20s to 40s. Epidermal inclusion cysts by themselves are usually not genetically linked. They can be hereditary in rare syndromes such as Gardner syndrome, nodular elastosis with cysts and comedones (Favre-Racouchot syndrome), and basal cell nevus syndrome (Gorlin syndrome). Elderly patients with chronic sun-damaged skin areas have a higher likelihood of developing epidermoid cysts. Patients on BRAF inhibitors such as imiquimod and cyclosporine have a higher incidence of epidermoid cysts of the face. They often occur in areas where hair follicles have been inflamed or repeatedly irritated.  They are more frequent in patients with acne vulgaris. They can be seen during the neonatal period known as milia. [1]

Pathophysiology

The epidermal inclusion cyst can be primary or secondary. Primary epidermal cysts arise directly from the infundibulum of the hair follicle. Plugging of the follicular orifice allows for cyst formation. The cyst often communicates with the surface of the skin through a small orifice or visible central punctum. Patients suffering from acne vulgaris have a higher rate of hair follicle disruption and pore blockages leading to a higher rate of epidermal inclusion cyst formation from preexisting comedones. Secondary epidermoid cysts can arise after the implantation of the follicular epithelium in the dermis due to trauma or comedone formation. Epidermoid cysts are lined with stratified squamous epithelium with the accumulation of keratin in the core. Recently, Human papillomavirus and chronic ultraviolet light exposure have been seen to allow epidermal cysts to form.

Additionally, the epidermal inclusion cysts can occur in any area of the body. Most often, they are found on the face, scalp, neck, back, and scrotum. Inclusion cysts found in unusual numbers or locations like the extremities, trunk, or the back of the ears may be seen in the setting of Gardner syndrome. Gardner syndrome or familial adenomatous polyposis (FAP) with extracolonic manifestations is an autosomal dominant inherited disease due to a mutation in the APC gene on chromosome 5. The cardinal clinical feature is innumerable, widespread colonic polyps in conjunction with extracolonic lesions. In this disease process, the epidermal cysts will often appear before the onset of puberty and may even precede the onset of colonic polyposis.[1]

Histopathology

Epidermoid inclusion cysts can be confirmed by histologic examination. Epidermal inclusion cysts, more specifically, demonstrate the implantation of epidermal elements into the dermis layer of the skin. The cyst wall is usually derived from the infundibular portion of the hair follicle. Thus, the majority of epidermal inclusion cysts may be referred to as an infundibular cyst. However, a cyst’s wall can be derived from another etiology, explaining the interchangeable yet inaccurate use of the two names. The cystic cavity is filled with laminated keratinous material. Often, a granular layer is present that is filled with keratohyalin granules. In the event a cyst ruptures, a keratin granuloma can be seen during the examination. Infected cysts microscopically can show disruption of the cyst wall, acute inflammation or neutrophil invasion, or intense foreign body giant cell reaction. Approximately less than 1% of epidermal inclusion cysts have a malignant transformation to basal cell carcinoma or squamous cell carcinoma.[4][5]

History and Physical

The diagnosis of epidermoid cysts is usually clinical. It is based upon the clinical appearance of a discrete, freely moveable cyst, often with a visible central punctum. These cysts can occur anywhere on the body and typically present as nodules directly underneath the patient’s skin. The size of a cyst can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge. There is no predictive modality to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. An infected cyst tends to be large with increased erythema, and it is more noticeable to the patient.

Furthermore, if inflammation is present, it usually results in cyst rupture and extrusion of cyst contents into the surrounding cutaneous and/or subcutaneous tissues, which may or may not be the result of an active infection. The source of infection for cysts usually comes from normal skin flora organisms, such as Staphylococcus aureus and Staphylococcus epidermidis. Generally, epidermal inclusion cysts are asymptomatic until they rupture.

Evaluation

Epidermoid inclusion cysts are evaluated by the history and physical exam often in an office setting. The need for pathology or histological examination before the operating room is usually not warranted. Radiographic and laboratory exams, such as ultrasound studies, are unnecessary and not typically ordered unless the evaluation leads the practitioner to suspect a genetic condition.

Treatment / Management

Inflamed, uninfected epidermal inclusion cysts rarely resolve spontaneously without therapy or surgical intervention. Treatment is not emergent unless desired by the patient electively before an increase in symptom severity (pain and/or infection). Definitive treatment is the surgical excision of the cyst. Some sources describe an alternative, yet not definitive, minimally invasive therapy for treatment, such as injecting triamcinolone at the dosage of 10 mg/mL for the trunk and 3 mg/mL for the face. The injection should be introduced into the inflamed epidermoid cyst, and it can help resolve the inflammation, prevent infection, and potentially reduce the need for surgical incision and drainage.

The definitive treatment is the complete surgical excision of the cyst with its walls intact; this will prevent reoccurrence. Excision is best accomplished when the lesion is not acutely inflamed. During this period, the cyst wall is friable, and the planes of dissection are more difficult to appreciate, making complete excision less likely and increasing the rate of reoccurrence.

For surgical excision, a local anesthetic, such as lidocaine with epinephrine, can be used. The anesthetic should be injected around the cyst, with care to avoid direct injection into the cyst, injection into the central pore, or rupture of the cyst wall. A small incision is made with a #11 blade on the skin overlying the cyst. The cyst contents are then expressed by exerting lateral pressure on either side of the cyst. With this technique, the cyst wall is often freed from the adjacent tissues and can be completely extracted through the small incision. The minimal incision surgical option provides better cosmetic results than the standard excision technique. Maintaining the incision within the minimal skin tension lines is important for cosmetic results. Reoccurrence rates from 1% to 8% have been shown with the minimal incision technique. A multiple layer subcuticular closure with an additional epidermal closure will yield better cosmetic outcomes.[6]

An alternate surgical option is to utilize a 4 mm punch biopsy with the expulsion of the intact cyst through the defect created in mass. Regardless of the option chosen, removal of the entire cystic wall is paramount to decrease reoccurrence.

In the event of a fluctuant lesion, incision and drainage are often needed with the mechanical destruction of intracavitary loculations. The presence of surrounding cellulitis may necessitate the use of oral antibiotic therapy. Empiric antibiotic therapy can be done with oral agents active against methicillin-sensitive S aureus or oral agents active against methicillin-resistant S aureus in areas of high prevalence. For patients who wish to have a more conservative treatment in the setting of acute infection, the cyst can be drained, and the patient started on oral antibiotics with a plan of surgical excision of remaining contents at a later date for definitive management. This is recommended due to a higher likelihood of reoccurrence without definitive surgical management.[4]

Differential Diagnosis

Depending on the anatomical area of the suspected epidermoid inclusion cysts, the differential diagnosis includes pilar cyst, lipoma, abscess, neuroma, benign growths, skin carcinomas, metastatic cutaneous lesions, pilomatrixoma, ganglion cyst, neurofibroma, dermoid cyst, brachial cleft cyst, pilonidal cyst, calcinosis cutis, pachyonychia congenita, steatocystoma simplex, and steatocystoma multiplex.

Prognosis

Epidermal inclusion cysts have an excellent prognosis after complete excision of all contents and the cystic wall.

Complications

Complications of epidermal inclusion cysts before definitive management can occur due to rupture and may result in symptoms such as erythema, pain, swelling, localized cellulitis. The main complication seen in clinical practice is reoccurrence due to incomplete excision. Any time surgery is done, there is a small inherent risk of complications. Complications of epidermal inclusion cyst excisions may include but are not limited to infection, bleeding, damage to surrounding structures and tissues, scarring, and wound dehiscence. There is a risk of the cyst reoccurring if the capsule is not completely excised during the surgical procedure.

Pearls and Other Issues

Differential diagnosis of epidermal inclusion cysts also include lipomas, neuromas, benign cutaneous growths, metastatic skin lesions, squamous cell carcinoma of the skin, basal cell carcinoma of the skin.

Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach to patient care can help achieve the best possible outcomes. Cutaneous lesions and cysts are often found by a primary care provider or the emergency room provider on the initial presentation. The primary care provider or emergency department provider will often identify an epidermoid inclusion cyst or other cutaneous lesions. Given the provider’s comfort level, they will then attempt to drain or remove the cutaneous lesion in the office. Often, this lesion turns out to be an epidermal inclusion cyst during the procedure, and there is not a complete excision of the cyst capsule. This incomplete removal can lead to complications such as infection, localized pain, and recurrence.

Additionally, the providers might order imaging of the lesion, such as an ultrasound, to further evaluate the lesion. If better communication can take place between healthcare providers, they could refer the patient to general surgery before any intervention. The surgeon may then offer definitive operative management and complete removal of the cyst capsule. Seeing a surgeon early in the care of a prospective epidermal cyst may also lead to a decrease in unnecessary imaging, which can also contribute to decreasing the overall cost of healthcare. Nurses should instruct patients about postoperative care and notify the surgeon if there are complications. This, in turn, provides the patient with a decreased chance of complications. From an overall healthcare system perspective, early referral and definitive treatment by a general surgeon for epidermoid inclusion cysts would lead to a single procedure for the patient, a higher level of patient satisfaction, decreased overall healthcare costs, and better patient outcomes.

Figure

Epidermal Cyst. Contributed by DermNetNZ

References

1.

Zito PM, Scharf R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 29, 2020. Epidermoid Cyst. [PubMed: 29763149]

2.

Boussemart L, Routier E, Mateus C, Opletalova K, Sebille G, Kamsu-Kom N, Thomas M, Vagner S, Favre M, Tomasic G, Wechsler J, Lacroix L, Robert C. Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: a study of 42 patients. Ann Oncol. 2013 Jun;24(6):1691-7. [PubMed: 23406731]

3.

Urabe K, Xia J, Masuda T, Moroi Y, Furue M, Matsumoto T. Pilomatricoma-like changes in the epidermoid cysts of Gardner syndrome with an APC gene mutation. J Dermatol. 2004 Mar;31(3):255-7. [PubMed: 15187352]

4.

Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002 Apr 01;65(7):1409-12, 1417-8, 1420. [PubMed: 11996426]

5.

Apollos JR, Ekatah GE, Ng GS, McFadyen AK, Whitelaw SC. Routine histological examination of epidermoid cysts; to send or not to send? Ann Med Surg (Lond). 2017 Jan;13:24-28. [PMC free article: PMC5198733] [PubMed: 28053700]

6.

Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: a prospective, randomized study. Dermatol Surg. 2006 Apr;32(4):520-5. [PubMed: 16681659]

Epidermal Inclusion Cyst – StatPearls

Continuing Education Activity

Epidermal inclusion cysts are the most common cutaneous cysts and can occur anywhere on the body. These cysts typically present as fluctuant nodules under the surface of the skin, often with visible central puncta. These cysts often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. This activity reviews the evaluation and management of epidermal inclusion cysts and highlights the importance of an interprofessional approach to caring for affected patients.

Objectives:

• Identify the etiology of epidermal inclusion cysts.

• Describe the evaluation of epidermal inclusion cysts.

• Describe the treatment and management options available for epidermal inclusion cysts.

• Explain interprofessional team strategies for improving care coordination and communication to advance the management of epidermal inclusion cysts and improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Epidermal inclusion cysts are the most common cutaneous cysts. Numerous synonyms for epidermal inclusion cysts exist, including epidermoid cyst, epidermal cyst, infundibular cyst, inclusion cyst, and keratin cyst. These cysts can occur anywhere on the body, typically present as nodules directly underneath the patient’s skin, and often have a visible central punctum. They are usually freely moveable. The size of these cysts can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge over time. There are no reliable predictive factors to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. Infected and/or fluctuant cysts tend to be larger, erythematous, and more noticeable to the patient. Due to the inflammatory response, the cyst will often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. The center of epidermoid cysts almost always contains keratin and not sebum. This keratin often has a “cheesy” appearance. They also do not originate from sebaceous glands; therefore, epidermal inclusion cysts are not sebaceous cysts. The term “sebaceous” cyst should not be used when describing an “epidermoid” cyst. Unfortunately, in practice, the terms are often used interchangeably.[1]

Etiology

The majority of epidermoid cysts are sporadic. Epidermal inclusion cysts are extremely common, benign, not contagious, and can appear to resolve on their own. Without definitive treatment, they can reoccur. They often occur in areas where hair follicles have been inflamed and are usually common in conjunction with acne.[1][2][3]

Epidemiology

They are more common in men than women, with a ration of 2:1. They occur more frequently in patients in their 20s to 40s. Epidermal inclusion cysts by themselves are usually not genetically linked. They can be hereditary in rare syndromes such as Gardner syndrome, nodular elastosis with cysts and comedones (Favre-Racouchot syndrome), and basal cell nevus syndrome (Gorlin syndrome). Elderly patients with chronic sun-damaged skin areas have a higher likelihood of developing epidermoid cysts. Patients on BRAF inhibitors such as imiquimod and cyclosporine have a higher incidence of epidermoid cysts of the face. They often occur in areas where hair follicles have been inflamed or repeatedly irritated.  They are more frequent in patients with acne vulgaris. They can be seen during the neonatal period known as milia.[1]

Pathophysiology

The epidermal inclusion cyst can be primary or secondary. Primary epidermal cysts arise directly from the infundibulum of the hair follicle. Plugging of the follicular orifice allows for cyst formation. The cyst often communicates with the surface of the skin through a small orifice or visible central punctum. Patients suffering from acne vulgaris have a higher rate of hair follicle disruption and pore blockages leading to a higher rate of epidermal inclusion cyst formation from preexisting comedones. Secondary epidermoid cysts can arise after the implantation of the follicular epithelium in the dermis due to trauma or comedone formation. Epidermoid cysts are lined with stratified squamous epithelium with the accumulation of keratin in the core. Recently, Human papillomavirus and chronic ultraviolet light exposure have been seen to allow epidermal cysts to form.

Additionally, the epidermal inclusion cysts can occur in any area of the body. Most often, they are found on the face, scalp, neck, back, and scrotum. Inclusion cysts found in unusual numbers or locations like the extremities, trunk, or the back of the ears may be seen in the setting of Gardner syndrome. Gardner syndrome or familial adenomatous polyposis (FAP) with extracolonic manifestations is an autosomal dominant inherited disease due to a mutation in the APC gene on chromosome 5. The cardinal clinical feature is innumerable, widespread colonic polyps in conjunction with extracolonic lesions. In this disease process, the epidermal cysts will often appear before the onset of puberty and may even precede the onset of colonic polyposis.[1]

Histopathology

Epidermoid inclusion cysts can be confirmed by histologic examination. Epidermal inclusion cysts, more specifically, demonstrate the implantation of epidermal elements into the dermis layer of the skin. The cyst wall is usually derived from the infundibular portion of the hair follicle. Thus, the majority of epidermal inclusion cysts may be referred to as an infundibular cyst. However, a cyst’s wall can be derived from another etiology, explaining the interchangeable yet inaccurate use of the two names. The cystic cavity is filled with laminated keratinous material. Often, a granular layer is present that is filled with keratohyalin granules. In the event a cyst ruptures, a keratin granuloma can be seen during the examination. Infected cysts microscopically can show disruption of the cyst wall, acute inflammation or neutrophil invasion, or intense foreign body giant cell reaction. Approximately less than 1% of epidermal inclusion cysts have a malignant transformation to basal cell carcinoma or squamous cell carcinoma.[4][5]

History and Physical

The diagnosis of epidermoid cysts is usually clinical. It is based upon the clinical appearance of a discrete, freely moveable cyst, often with a visible central punctum. These cysts can occur anywhere on the body and typically present as nodules directly underneath the patient’s skin. The size of a cyst can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge. There is no predictive modality to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. An infected cyst tends to be large with increased erythema, and it is more noticeable to the patient.

Furthermore, if inflammation is present, it usually results in cyst rupture and extrusion of cyst contents into the surrounding cutaneous and/or subcutaneous tissues, which may or may not be the result of an active infection. The source of infection for cysts usually comes from normal skin flora organisms, such as Staphylococcus aureus and Staphylococcus epidermidis. Generally, epidermal inclusion cysts are asymptomatic until they rupture.

Evaluation

Epidermoid inclusion cysts are evaluated by the history and physical exam often in an office setting. The need for pathology or histological examination before the operating room is usually not warranted. Radiographic and laboratory exams, such as ultrasound studies, are unnecessary and not typically ordered unless the evaluation leads the practitioner to suspect a genetic condition.

Treatment / Management

Inflamed, uninfected epidermal inclusion cysts rarely resolve spontaneously without therapy or surgical intervention. Treatment is not emergent unless desired by the patient electively before an increase in symptom severity (pain and/or infection). Definitive treatment is the surgical excision of the cyst. Some sources describe an alternative, yet not definitive, minimally invasive therapy for treatment, such as injecting triamcinolone at the dosage of 10 mg/mL for the trunk and 3 mg/mL for the face. The injection should be introduced into the inflamed epidermoid cyst, and it can help resolve the inflammation, prevent infection, and potentially reduce the need for surgical incision and drainage.

The definitive treatment is the complete surgical excision of the cyst with its walls intact; this will prevent reoccurrence. Excision is best accomplished when the lesion is not acutely inflamed. During this period, the cyst wall is friable, and the planes of dissection are more difficult to appreciate, making complete excision less likely and increasing the rate of reoccurrence.

For surgical excision, a local anesthetic, such as lidocaine with epinephrine, can be used. The anesthetic should be injected around the cyst, with care to avoid direct injection into the cyst, injection into the central pore, or rupture of the cyst wall. A small incision is made with a #11 blade on the skin overlying the cyst. The cyst contents are then expressed by exerting lateral pressure on either side of the cyst. With this technique, the cyst wall is often freed from the adjacent tissues and can be completely extracted through the small incision. The minimal incision surgical option provides better cosmetic results than the standard excision technique. Maintaining the incision within the minimal skin tension lines is important for cosmetic results. Reoccurrence rates from 1% to 8% have been shown with the minimal incision technique. A multiple layer subcuticular closure with an additional epidermal closure will yield better cosmetic outcomes.[6]

An alternate surgical option is to utilize a 4 mm punch biopsy with the expulsion of the intact cyst through the defect created in mass. Regardless of the option chosen, removal of the entire cystic wall is paramount to decrease reoccurrence.

In the event of a fluctuant lesion, incision and drainage are often needed with the mechanical destruction of intracavitary loculations. The presence of surrounding cellulitis may necessitate the use of oral antibiotic therapy. Empiric antibiotic therapy can be done with oral agents active against methicillin-sensitive S aureus or oral agents active against methicillin-resistant S aureus in areas of high prevalence. For patients who wish to have a more conservative treatment in the setting of acute infection, the cyst can be drained, and the patient started on oral antibiotics with a plan of surgical excision of remaining contents at a later date for definitive management. This is recommended due to a higher likelihood of reoccurrence without definitive surgical management.[4]

Differential Diagnosis

Depending on the anatomical area of the suspected epidermoid inclusion cysts, the differential diagnosis includes pilar cyst, lipoma, abscess, neuroma, benign growths, skin carcinomas, metastatic cutaneous lesions, pilomatrixoma, ganglion cyst, neurofibroma, dermoid cyst, brachial cleft cyst, pilonidal cyst, calcinosis cutis, pachyonychia congenita, steatocystoma simplex, and steatocystoma multiplex.

Prognosis

Epidermal inclusion cysts have an excellent prognosis after complete excision of all contents and the cystic wall.

Complications

Complications of epidermal inclusion cysts before definitive management can occur due to rupture and may result in symptoms such as erythema, pain, swelling, localized cellulitis. The main complication seen in clinical practice is reoccurrence due to incomplete excision. Any time surgery is done, there is a small inherent risk of complications. Complications of epidermal inclusion cyst excisions may include but are not limited to infection, bleeding, damage to surrounding structures and tissues, scarring, and wound dehiscence. There is a risk of the cyst reoccurring if the capsule is not completely excised during the surgical procedure.

Pearls and Other Issues

Differential diagnosis of epidermal inclusion cysts also include lipomas, neuromas, benign cutaneous growths, metastatic skin lesions, squamous cell carcinoma of the skin, basal cell carcinoma of the skin.

Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach to patient care can help achieve the best possible outcomes. Cutaneous lesions and cysts are often found by a primary care provider or the emergency room provider on the initial presentation. The primary care provider or emergency department provider will often identify an epidermoid inclusion cyst or other cutaneous lesions. Given the provider’s comfort level, they will then attempt to drain or remove the cutaneous lesion in the office. Often, this lesion turns out to be an epidermal inclusion cyst during the procedure, and there is not a complete excision of the cyst capsule. This incomplete removal can lead to complications such as infection, localized pain, and recurrence.

Additionally, the providers might order imaging of the lesion, such as an ultrasound, to further evaluate the lesion. If better communication can take place between healthcare providers, they could refer the patient to general surgery before any intervention. The surgeon may then offer definitive operative management and complete removal of the cyst capsule. Seeing a surgeon early in the care of a prospective epidermal cyst may also lead to a decrease in unnecessary imaging, which can also contribute to decreasing the overall cost of healthcare. Nurses should instruct patients about postoperative care and notify the surgeon if there are complications. This, in turn, provides the patient with a decreased chance of complications. From an overall healthcare system perspective, early referral and definitive treatment by a general surgeon for epidermoid inclusion cysts would lead to a single procedure for the patient, a higher level of patient satisfaction, decreased overall healthcare costs, and better patient outcomes.

Figure

Epidermal Cyst. Contributed by DermNetNZ

References

1.

Zito PM, Scharf R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 29, 2020. Epidermoid Cyst. [PubMed: 29763149]

2.

Boussemart L, Routier E, Mateus C, Opletalova K, Sebille G, Kamsu-Kom N, Thomas M, Vagner S, Favre M, Tomasic G, Wechsler J, Lacroix L, Robert C. Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: a study of 42 patients. Ann Oncol. 2013 Jun;24(6):1691-7. [PubMed: 23406731]

3.

Urabe K, Xia J, Masuda T, Moroi Y, Furue M, Matsumoto T. Pilomatricoma-like changes in the epidermoid cysts of Gardner syndrome with an APC gene mutation. J Dermatol. 2004 Mar;31(3):255-7. [PubMed: 15187352]

4.

Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002 Apr 01;65(7):1409-12, 1417-8, 1420. [PubMed: 11996426]

5.

Apollos JR, Ekatah GE, Ng GS, McFadyen AK, Whitelaw SC. Routine histological examination of epidermoid cysts; to send or not to send? Ann Med Surg (Lond). 2017 Jan;13:24-28. [PMC free article: PMC5198733] [PubMed: 28053700]

6.

Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: a prospective, randomized study. Dermatol Surg. 2006 Apr;32(4):520-5. [PubMed: 16681659]

Epidermal Inclusion Cyst – StatPearls

Continuing Education Activity

Epidermal inclusion cysts are the most common cutaneous cysts and can occur anywhere on the body. These cysts typically present as fluctuant nodules under the surface of the skin, often with visible central puncta. These cysts often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. This activity reviews the evaluation and management of epidermal inclusion cysts and highlights the importance of an interprofessional approach to caring for affected patients.

Objectives:

• Identify the etiology of epidermal inclusion cysts.

• Describe the evaluation of epidermal inclusion cysts.

• Describe the treatment and management options available for epidermal inclusion cysts.

• Explain interprofessional team strategies for improving care coordination and communication to advance the management of epidermal inclusion cysts and improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Epidermal inclusion cysts are the most common cutaneous cysts. Numerous synonyms for epidermal inclusion cysts exist, including epidermoid cyst, epidermal cyst, infundibular cyst, inclusion cyst, and keratin cyst. These cysts can occur anywhere on the body, typically present as nodules directly underneath the patient’s skin, and often have a visible central punctum. They are usually freely moveable. The size of these cysts can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge over time. There are no reliable predictive factors to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. Infected and/or fluctuant cysts tend to be larger, erythematous, and more noticeable to the patient. Due to the inflammatory response, the cyst will often become painful to the patient and may present as a fluctuant filled nodule below the patient’s skin. The center of epidermoid cysts almost always contains keratin and not sebum. This keratin often has a “cheesy” appearance. They also do not originate from sebaceous glands; therefore, epidermal inclusion cysts are not sebaceous cysts. The term “sebaceous” cyst should not be used when describing an “epidermoid” cyst. Unfortunately, in practice, the terms are often used interchangeably.[1]

Etiology

The majority of epidermoid cysts are sporadic. Epidermal inclusion cysts are extremely common, benign, not contagious, and can appear to resolve on their own. Without definitive treatment, they can reoccur. They often occur in areas where hair follicles have been inflamed and are usually common in conjunction with acne.[1][2][3]

Epidemiology

They are more common in men than women, with a ration of 2:1. They occur more frequently in patients in their 20s to 40s. Epidermal inclusion cysts by themselves are usually not genetically linked. They can be hereditary in rare syndromes such as Gardner syndrome, nodular elastosis with cysts and comedones (Favre-Racouchot syndrome), and basal cell nevus syndrome (Gorlin syndrome). Elderly patients with chronic sun-damaged skin areas have a higher likelihood of developing epidermoid cysts. Patients on BRAF inhibitors such as imiquimod and cyclosporine have a higher incidence of epidermoid cysts of the face. They often occur in areas where hair follicles have been inflamed or repeatedly irritated.  They are more frequent in patients with acne vulgaris. They can be seen during the neonatal period known as milia.[1]

Pathophysiology

The epidermal inclusion cyst can be primary or secondary. Primary epidermal cysts arise directly from the infundibulum of the hair follicle. Plugging of the follicular orifice allows for cyst formation. The cyst often communicates with the surface of the skin through a small orifice or visible central punctum. Patients suffering from acne vulgaris have a higher rate of hair follicle disruption and pore blockages leading to a higher rate of epidermal inclusion cyst formation from preexisting comedones. Secondary epidermoid cysts can arise after the implantation of the follicular epithelium in the dermis due to trauma or comedone formation. Epidermoid cysts are lined with stratified squamous epithelium with the accumulation of keratin in the core. Recently, Human papillomavirus and chronic ultraviolet light exposure have been seen to allow epidermal cysts to form.

Additionally, the epidermal inclusion cysts can occur in any area of the body. Most often, they are found on the face, scalp, neck, back, and scrotum. Inclusion cysts found in unusual numbers or locations like the extremities, trunk, or the back of the ears may be seen in the setting of Gardner syndrome. Gardner syndrome or familial adenomatous polyposis (FAP) with extracolonic manifestations is an autosomal dominant inherited disease due to a mutation in the APC gene on chromosome 5. The cardinal clinical feature is innumerable, widespread colonic polyps in conjunction with extracolonic lesions. In this disease process, the epidermal cysts will often appear before the onset of puberty and may even precede the onset of colonic polyposis.[1]

Histopathology

Epidermoid inclusion cysts can be confirmed by histologic examination. Epidermal inclusion cysts, more specifically, demonstrate the implantation of epidermal elements into the dermis layer of the skin. The cyst wall is usually derived from the infundibular portion of the hair follicle. Thus, the majority of epidermal inclusion cysts may be referred to as an infundibular cyst. However, a cyst’s wall can be derived from another etiology, explaining the interchangeable yet inaccurate use of the two names. The cystic cavity is filled with laminated keratinous material. Often, a granular layer is present that is filled with keratohyalin granules. In the event a cyst ruptures, a keratin granuloma can be seen during the examination. Infected cysts microscopically can show disruption of the cyst wall, acute inflammation or neutrophil invasion, or intense foreign body giant cell reaction. Approximately less than 1% of epidermal inclusion cysts have a malignant transformation to basal cell carcinoma or squamous cell carcinoma.[4][5]

History and Physical

The diagnosis of epidermoid cysts is usually clinical. It is based upon the clinical appearance of a discrete, freely moveable cyst, often with a visible central punctum. These cysts can occur anywhere on the body and typically present as nodules directly underneath the patient’s skin. The size of a cyst can range from a few millimeters to several centimeters in diameter. Lesions may remain stable or progressively enlarge. There is no predictive modality to tell if an epidermal inclusion cyst will enlarge, become inflamed, or remain quiescent. An infected cyst tends to be large with increased erythema, and it is more noticeable to the patient.

Furthermore, if inflammation is present, it usually results in cyst rupture and extrusion of cyst contents into the surrounding cutaneous and/or subcutaneous tissues, which may or may not be the result of an active infection. The source of infection for cysts usually comes from normal skin flora organisms, such as Staphylococcus aureus and Staphylococcus epidermidis. Generally, epidermal inclusion cysts are asymptomatic until they rupture.

Evaluation

Epidermoid inclusion cysts are evaluated by the history and physical exam often in an office setting. The need for pathology or histological examination before the operating room is usually not warranted. Radiographic and laboratory exams, such as ultrasound studies, are unnecessary and not typically ordered unless the evaluation leads the practitioner to suspect a genetic condition.

Treatment / Management

Inflamed, uninfected epidermal inclusion cysts rarely resolve spontaneously without therapy or surgical intervention. Treatment is not emergent unless desired by the patient electively before an increase in symptom severity (pain and/or infection). Definitive treatment is the surgical excision of the cyst. Some sources describe an alternative, yet not definitive, minimally invasive therapy for treatment, such as injecting triamcinolone at the dosage of 10 mg/mL for the trunk and 3 mg/mL for the face. The injection should be introduced into the inflamed epidermoid cyst, and it can help resolve the inflammation, prevent infection, and potentially reduce the need for surgical incision and drainage.

The definitive treatment is the complete surgical excision of the cyst with its walls intact; this will prevent reoccurrence. Excision is best accomplished when the lesion is not acutely inflamed. During this period, the cyst wall is friable, and the planes of dissection are more difficult to appreciate, making complete excision less likely and increasing the rate of reoccurrence.

For surgical excision, a local anesthetic, such as lidocaine with epinephrine, can be used. The anesthetic should be injected around the cyst, with care to avoid direct injection into the cyst, injection into the central pore, or rupture of the cyst wall. A small incision is made with a #11 blade on the skin overlying the cyst. The cyst contents are then expressed by exerting lateral pressure on either side of the cyst. With this technique, the cyst wall is often freed from the adjacent tissues and can be completely extracted through the small incision. The minimal incision surgical option provides better cosmetic results than the standard excision technique. Maintaining the incision within the minimal skin tension lines is important for cosmetic results. Reoccurrence rates from 1% to 8% have been shown with the minimal incision technique. A multiple layer subcuticular closure with an additional epidermal closure will yield better cosmetic outcomes.[6]

An alternate surgical option is to utilize a 4 mm punch biopsy with the expulsion of the intact cyst through the defect created in mass. Regardless of the option chosen, removal of the entire cystic wall is paramount to decrease reoccurrence.

In the event of a fluctuant lesion, incision and drainage are often needed with the mechanical destruction of intracavitary loculations. The presence of surrounding cellulitis may necessitate the use of oral antibiotic therapy. Empiric antibiotic therapy can be done with oral agents active against methicillin-sensitive S aureus or oral agents active against methicillin-resistant S aureus in areas of high prevalence. For patients who wish to have a more conservative treatment in the setting of acute infection, the cyst can be drained, and the patient started on oral antibiotics with a plan of surgical excision of remaining contents at a later date for definitive management. This is recommended due to a higher likelihood of reoccurrence without definitive surgical management.[4]

Differential Diagnosis

Depending on the anatomical area of the suspected epidermoid inclusion cysts, the differential diagnosis includes pilar cyst, lipoma, abscess, neuroma, benign growths, skin carcinomas, metastatic cutaneous lesions, pilomatrixoma, ganglion cyst, neurofibroma, dermoid cyst, brachial cleft cyst, pilonidal cyst, calcinosis cutis, pachyonychia congenita, steatocystoma simplex, and steatocystoma multiplex.

Prognosis

Epidermal inclusion cysts have an excellent prognosis after complete excision of all contents and the cystic wall.

Complications

Complications of epidermal inclusion cysts before definitive management can occur due to rupture and may result in symptoms such as erythema, pain, swelling, localized cellulitis. The main complication seen in clinical practice is reoccurrence due to incomplete excision. Any time surgery is done, there is a small inherent risk of complications. Complications of epidermal inclusion cyst excisions may include but are not limited to infection, bleeding, damage to surrounding structures and tissues, scarring, and wound dehiscence. There is a risk of the cyst reoccurring if the capsule is not completely excised during the surgical procedure.

Pearls and Other Issues

Differential diagnosis of epidermal inclusion cysts also include lipomas, neuromas, benign cutaneous growths, metastatic skin lesions, squamous cell carcinoma of the skin, basal cell carcinoma of the skin.

Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach to patient care can help achieve the best possible outcomes. Cutaneous lesions and cysts are often found by a primary care provider or the emergency room provider on the initial presentation. The primary care provider or emergency department provider will often identify an epidermoid inclusion cyst or other cutaneous lesions. Given the provider’s comfort level, they will then attempt to drain or remove the cutaneous lesion in the office. Often, this lesion turns out to be an epidermal inclusion cyst during the procedure, and there is not a complete excision of the cyst capsule. This incomplete removal can lead to complications such as infection, localized pain, and recurrence.

Additionally, the providers might order imaging of the lesion, such as an ultrasound, to further evaluate the lesion. If better communication can take place between healthcare providers, they could refer the patient to general surgery before any intervention. The surgeon may then offer definitive operative management and complete removal of the cyst capsule. Seeing a surgeon early in the care of a prospective epidermal cyst may also lead to a decrease in unnecessary imaging, which can also contribute to decreasing the overall cost of healthcare. Nurses should instruct patients about postoperative care and notify the surgeon if there are complications. This, in turn, provides the patient with a decreased chance of complications. From an overall healthcare system perspective, early referral and definitive treatment by a general surgeon for epidermoid inclusion cysts would lead to a single procedure for the patient, a higher level of patient satisfaction, decreased overall healthcare costs, and better patient outcomes.

Figure

Epidermal Cyst. Contributed by DermNetNZ

References

1.

Zito PM, Scharf R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 29, 2020. Epidermoid Cyst. [PubMed: 29763149]

2.

Boussemart L, Routier E, Mateus C, Opletalova K, Sebille G, Kamsu-Kom N, Thomas M, Vagner S, Favre M, Tomasic G, Wechsler J, Lacroix L, Robert C. Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: a study of 42 patients. Ann Oncol. 2013 Jun;24(6):1691-7. [PubMed: 23406731]

3.

Urabe K, Xia J, Masuda T, Moroi Y, Furue M, Matsumoto T. Pilomatricoma-like changes in the epidermoid cysts of Gardner syndrome with an APC gene mutation. J Dermatol. 2004 Mar;31(3):255-7. [PubMed: 15187352]

4.

Zuber TJ. Minimal excision technique for epidermoid (sebaceous) cysts. Am Fam Physician. 2002 Apr 01;65(7):1409-12, 1417-8, 1420. [PubMed: 11996426]

5.

Apollos JR, Ekatah GE, Ng GS, McFadyen AK, Whitelaw SC. Routine histological examination of epidermoid cysts; to send or not to send? Ann Med Surg (Lond). 2017 Jan;13:24-28. [PMC free article: PMC5198733] [PubMed: 28053700]

6.

Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: a prospective, randomized study. Dermatol Surg. 2006 Apr;32(4):520-5. [PubMed: 16681659]

What is a keratinous cyst?

Cutaneous cysts and pseudocysts | DermNet NZ

Author: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, 1997. Updated February 2016.

What is a cyst?

A cyst is a benign, round, dome-shaped encapsulated lesion that contains fluid or semi-fluid material. It may be firm or fluctuant and often distends the overlying skin. There are several types of cyst. The most common are described here.

What is a pseudocyst?

Cysts that are not surrounded by a capsule are better known as pseudocysts. These commonly arise in acne. 

Who gets cysts?

Cysts are very common, affecting at least 20% of adults. They may be present at birth or appear later in life. They arise in all races. Most types of cyst are more common in males than in females.

What causes cysts?

The cause of many cysts is unknown.

• Epidermoid cysts are due to the proliferation of epidermal cells within the dermis. Their origin is the follicular infundibulum. Multiple epidermoid cysts may indicate Gardner syndrome. The common term, sebaceous cyst, is a misnomer.
• An epidermal inclusion cyst is a response to an injury. Skin is tucked in to form a sac that is lined by healthy epidermal cells that continue to multiply, mature and form keratin. 
• The origin of a trichilemmal cyst is hair root sheath. Inheritance is autosomal dominant (the affected gene is within the short arm of chromosome 3) or sporadic.
• The origin of steatocystoma is the sebaceous duct within the hair follicle. Steatocystoma multiplex is sometimes an autosomal dominantly inherited disorder due to mutations localised to the keratin 17 (K17) gene, when it may be associated with pachyonychia congenita. More often, steatocysts are sporadic, when these mutations are not present.
• The origin of the eruptive vellus hair cyst is follicular infundibulum. It may be inherited as an autosomal dominant disorder due to mutations in the keratin gene. 
• A dermoid cyst is a hamartoma, a developmental error.
• The origin of a ganglion cyst is degeneration of the mucoid connective tissue of a joint.  
• Occlusion of pilosebaceous units (hair follicles) or eccrine sweat ducts leads to a build-up of secretions, which can present as milia.
• Occlusion of the orifice of a mucous gland can lead to a fluid-filled mucocoele in a mucous membrane (lip, vulva, vagina).
• A milium is a pseudocyst due to failure to release keratin from an adnexal structure. The origin of primary milium is infundibulum of the vellus hair follicle at the level of the sebaceous gland and is a miniature version of an epidermoid cyst. The source of secondary milium is a retention cyst within a vellus hair follicle, sebaceous duct, sweat duct or epidermis.
• Pseudocysts in acne are formed by occlusion of the follicle by keratin and sebum.

What are the clinical features of cysts?

Epidermoid cyst

• Epidermoid cysts occur on face, neck, trunk or anywhere where there is little hair.
• Most epidermoid cysts arise in adult life.
• They are more than twice as common in men as in women.
• They present as one or more flesh–coloured to yellowish, adherent, firm, round nodules of variable size.
• A central pore or punctum may be present.
• Keratinous contents are soft, cheese-like and malodorous.
• Scrotal and vulval cysts are frequently multiple and may calcify.

An epidermoid cyst is also called a follicular infundibular cyst, epidermal cyst, and keratin cyst.

Epidermoid cyst

See more images of epidermoid cysts.

Trichilemmal cyst

• 90% of trichilemmal cysts occur on the scalp; otherwise face, neck, trunk, and extremities.
• Most trichilemmal cysts arise in middle age.
• In 70% of cases, trichilemmal cysts are multiple.
• They present as adherent, round or oval, firm nodules.
• There is no punctum.
• The keratinous content is firm, white and easily enucleated.

A trichilemmal cyst is also called pilar cyst.

Trichilemmal cyst

See more images of epidermoid cysts.

Steatocystoma

• A solitary steatocystoma is known as steatocystoma simplex.
• More often, there are multiple lesions (steatocystoma multiplex) on the chest, upper arms, axillae, neck and scrotum or vulva.
• The cysts arise in the late teens and 20s due to the effect of androgens and persist lifelong.
• They are freely moveable, smooth flesh to yellow colour papules 3–30 mm in diameter.
• There is no central punctum.
• Content of cyst is predominantly sebum.

Steatocystoma multiplex

Eruptive vellus hair cysts

Dermoid cyst

• A cutaneous dermoid cyst may include skin, skin structures and sometimes teeth, cartilage and bone.
• Most dermoid cysts are found on face, neck, scalp; often around eyelid, forehead and brow.
• It is a thin-walled tumour that ranges from soft to hard in consistency.
• The cyst is formed at birth, but the patient may not present until an adult.

Dermoid cysts

Ganglion cyst

• A ganglion cyst most often involves the scapholunate joint of the dorsal wrist.
• These arise in young to middle-aged adults.
• They are three times more common in women than in men.
• The cyst is a unilocular or multilocular firm swelling 2–4 cm in diameter that transilluminates.
• Cyst contents are mainly hyaluronic acid, a golden-coloured goo.

Ganglion cyst

Digital myxoid pseudocyst

• Mucous/myxoid pseudocysts arise in older adults on the distal phalanx
• They arise from distal interphalangeal joint, associated with osteoarthritis.
• They often present as a longitudinal depression in the nail due to compression on the proximal matrix.

Myxoid pseudocyst

See more images of digital myxoid pseudocysts.

Labial mucous/myxoid cyst

• A cyst in the lip may be due to occlusion of the salivary duct
• A labial cyst is also called a mucocoele.
• It is a soft to firm, 5–15 mm diameter, semi-translucent nodule.

Mucocoele of lip

Hidrocystoma

• Hidrocystoma is a translucent jelly-like cyst arising on an eyelid.
• It is also known as cystadenoma, Moll gland cyst, and sudoriferous cyst.
• The common solitary translucent eyelid cyst is an apocrine hidrocystoma.
• Multiple cysts on the lower eyelid are eccrine hidrocystomas.
• Link to apocrine hidrocystoma – pathology.

Hidrocystoma of eyelid

More images of hidrocystoma of the eyelid.

Milium/milia

• Milia are 1–2 mm superficial white dome-shaped papules containing keratin
• Primary milia arise in neonates (50%), adolescents and adults; they are rarely familial and sometimes eruptive.
• Primary milia occur on eyelids, cheeks, nose, mucosa (Epstein pearls) and palate (Bohn nodules) in babies; and eyelids, cheeks and nose of older children and adults.
• Transverse primary milia are sometimes noted across the nasal groove or around the areola.
• In milia en plaque, multiple milia arise on an erythematous plaque on face, chin or ears.
• Secondary milia arise at the site of epidermal repair after blistering or injury, in epidermolysis bullosa, bullous pemphigoid, porphyria cutanea tarda, thermal burn, and after dermabrasion.
• Secondary milia are reported as an adverse effect of topical steroids, 5-fluorouracil cream, vemurafenib and dovitinib.

Milia

See more images of milia.

Vulval mucous cyst

• A vulval mucous cyst is due to occlusion of Bartholin or Skene duct.
• It presents as a soft swelling in the introitus of the vagina: a posterior swelling is a Bartholin cyst and a periurethral swelling is a Skene cyst.

Comedo and acne pseudocyst

Comedones

Pseudocyst of auricle

Pseudocyst of auricle

Complications of cysts

Rupture of a cyst

• The contents of the cyst may penetrate the capsular wall and irritate the surrounding skin.
• The area of tender, firm inflammation spreads beyond the encapsulated cyst.
• Sterile pus may be discharged.

Secondary infection

Pressure effect

• A dermoid cyst can cause pressure on underlying bony tissue.
• A ganglion cyst can cause joint instability, weakness, limitation of motion and may compress a nerve.
• A digital mucous cyst may place pressure on the proximal matrix and cause a malformation of the nail.

Malignancy

• Cutaneous cysts and pseudocysts are non-proliferative benign lesions.
• Nodulocystic basal cell carcinoma is a common skin cancer that presents as a rounded nodule and may initially be mistaken for a cyst, but steady enlargement, destruction of the epidermis with ulceration and bleeding occur eventually.
• A malignant proliferative trichilemmal cyst is a misnomer. It is an extremely rare tumour.

How are cysts diagnosed?

Cysts have typical clinical characteristics. When a cyst is surgically removed, it should undergo a histological examination. The type of lining of the wall of the cyst and the cyst contents help the pathologist classify it.

• An epidermoid cyst is lined with stratified squamous epithelium that contains a granular layer. Laminated keratin contents are noted inside the cyst. An inflammatory response may be present in cysts that have ruptured.
• Trichilemmal cysts have a palisaded outer layer without a granular layer. The contents are eosinophilic hair keratin. Older cysts may exhibit calcification. The proliferating variety is considered a tumour.
• Steatocystoma has a folded cyst wall with prominent sebaceous gland lobules.
• A dermoid cyst contains fully mature elements of the skin including fat, hairs, sebaceous glands, eccrine glands, and in 20%, apocrine glands.
• The lining of the wall of a ganglion cyst or digital mucous cyst is collagen and fibrocytes. It contains hyaline material.
• Hidrocystoma has a thin lining wall of eosinophilic bilaminar cells.

What is the treatment for cysts?

An asymptomatic epidermoid cyst does not need to be treated. In most cases, an attempt to remove only the contents of a cyst is followed by recurrence. If desired, cysts may be entirely excised. Recurrence is not uncommon, and re-excision may be surgically challenging.

Inflamed cysts are sometimes treated with:

How can cysts be prevented?

Unknown.

What is the outlook for cysts?

Cysts generally persist unless surgically removed.

Cholesteatoma Skin Cyst in Middle Ear

Cholesteatomas are tumor like growths in the middle ear. They are generally formed from the skin cells on the outside of the eardrum that have become folded into the middle ear (retraction pocket) as a result of ear infections or with a perforation of the eardrum. The squamous epithelium, or skin layer, of the outside of the eardrum is continuously replaced and the old skin elements are meant to come out through the ear canal. When these skin elements become trapped behind the eardrum in the middle ear or mastoid, it is called a cholesteatoma. A cholesteatoma cyst consists of layers of scaly or keratinized (horny) layers of epithelium, which may also contain cholesterol crystals. This cyst typically grows very slowly and begins to cause symptoms as it compresses and erodes the structures of the middle ear and surrounding areas. Often the debris is infected with bacteria or other organisms, causing drainage and foul smell.

Cholesteatomas generally occur as a result of infection, and are called acquired cholesteatoma. These are the most common type of cholesteatoma. This type of cholesteatoma may occur at any age. The other type of cholesteatoma is congenital cholesteatoma, which occurs much less commonly. In this type, skin cells are trapped in the middle ear from birth. These skin cells grow in the middle ear and have no way of coming out of the middle ear cavity because of the intact eardrum. The typical age of presentation for the congenital cholesteatoma is 4-6 years old.

SIGNS AND SYMPTOMS:

Early symptoms of cholesteatoma include hearing loss, mucopurulent (brown/yellow) drainage from the ear, ear bleeding, ear pain, tinnitus and vertigo. A previous history of middle ear disease, such as chronic otitis media and/or eardrum perforation, is usually present.

On examination, a retraction pocket may be seen, often in the upper part of the eardrum. Accumulation of squamous skin debris may occur within the pocket. Granulation tissue (inflammatory tissue) may arise from the diseased infected bone of the ear canal wall. When extensive, a polyp may protrude into the ear canal from the cholesteatoma pocket.

MECHANISM OF DAMAGE

Damage to the middle and inner ear from a cholesteatoma is due to erosion and expansion of the cholesteatoma. This generally occurs gradually over years. If untreated, a cholesteatoma can eat into the three small bones located in the middle ear (the malleus, incus and stapes, collectively called ossicles) and into the inner ear, which can result in nerve deterioration, deafness, imbalance and vertigo. It can also affect and erode, through the enzymes it produces, the thin bone structure that separates the top of the ear from the brain. Erosion of this bone can lead to infections in the brain with serious complications. Cholesteatoma can also cause damage to the facial nerve that runs through the middle ear and supplies the facial muscles. Injury to this nerve from the cholesteatoma can cause facial paralysis.

DIAGNOSIS OF CHOLESTEATOMA

Cholesteatoma is diagnosed with a thorough clinical examination. Any debris is cleared from the ear canal and the eardrum and middle ear are assessed for any evidence of cholesteatoma.

An audiogram, or hearing test, is performed with air and bone conduction, speech reception thresholds, and word recognition. These tests adequately identify any hearing loss. A conductive hearing loss is common with cholesteatoma, usually from erosion of the ossicles causing a defect in the ossicular chain. The extent of the cholesteatoma and erosion of the ossicular chain determines the severity of the hearing loss.

At times, CT scan of the temporal bone may be performed to evaluate the anatomy, which may reveal evidence of the extent of the disease. A CT scan is not essential for evaluation of a cholesteatoma, but may be performed if your surgeon would like further information before definitive treatment

MANAGEMENT OF CHOLESTEATOMAS

Cholesteatoma is treated surgically with a primary goal of total eradication of the disease to obtain a safe and dry ear. The second objective is restoration or maintaining the functional capacity of hearing.

The surgical procedure used is designed for each individual case according to the extent of disease. More extensive disease will usually dictate a more aggressive surgical approach. Surgical treatment is typically broken down into two broad categories:

Intact Canal Wall Mastoidectomy

The mastoid bone behind the ear canal is drilled and all disease is removed from the mastoid cavity in this procedure. In addition, the area around the heads of the hearing bones is inspected and any cholesteatoma disease is cleared using this approach. An intact canal wall mastoidectomy maintains the normal ear canal, and the mastoid cavity cannot be visualized in the office (as it can be with a canal wall down mastoidectomy).

The ossicles in the middle ear cavity may be reconstructed depending on the extent of the cholesteatoma. If there has been erosion of one of the hearing bones, it may be replaced with a synthetic prosthesis to restore hearing to the ear.

Canal-Wall-Down (CWD) Procedure

This procedure involves removing the ear canal wall that separates the ear canal from the mastoid cavity behind it. This procedure creates a large cavity that can be easily examined through the ear canal opening. Thus, all cholesteatoma disease is removed from the ear and the large mastoid cavity is cleaned intermittently in the office. A procedure to enlarge the opening of the ear canal (meatoplasty) is always performed to allow aeration of the mastoid cavity and to permit easy visualization in the office to permit postoperative care and self-cleaning.

The advantages of the CWD procedure are that residual disease is easily detected and recurrent disease is rare. The major disadvantage of this procedure is the open cavity and that mastoid bowl maintenance can be a lifelong problem. Healing takes longer in open cavities and the middle ear is shallow and it is more difficult to reconstruct hearing. Dry ear precautions are essential.

Cholesteatoma Frequently Asked Questions

CLICK HERE FOR Cholesteatoma Frequently Asked Questions

SUMMARY:

Cholesteatoma can cause significant problems when left untreated. Surgery is the mainstay of treatment for this disease process. Long term follow up is critical to ensure that the entire disease process has been eradicated.

Treatment of cysts and granulomas Kiev, cost | Dentistry Artis

Cyst on the tooth and granuloma are diseases of the roots of the tooth. It is known that the history of dental granuloma most often begins with chronic periodontitis – an inflammatory process of a thin layer of the gum between the tooth root and the jaw bone. If it is left untreated, tissue overgrowth can begin in the inflamed area, around the apex of the tooth root. This growth is called a granuloma.

We will be happy to provide you with assistance at the highest level, as painlessly as possible, using modern technologies and the rich experience of the doctors of our clinic.

Cost of cyst / granuloma treatment

Granuloma and tooth cyst: symptoms

Symptoms of a tooth cyst are identical with those of a granuloma. The difficulty of diagnosing a granuloma at an early stage of its development is that, until a certain time, the presence of a neoplasm may be invisible to both the patient and the dentist. Visually on the inflamed area of ​​the gums there are outwardly healthy teeth.

The proliferation of granular tissues in the area of ​​the neoplasm occurs rapidly. As it increases, pain comes, swelling of the gums. Suppuration begins to develop. This causes a sharp pain in the gums, its redness and swelling. Purulent discharge may appear between the tooth and the gum, and the tooth may darken.

Difference between cyst and granuloma

At the time of detection of a tissue neoplasm at the root of the tooth, the doctor classifies it.

Tooth granuloma is a disease in which, as a result of inflammation, a neoplasm appears on the root of the tooth, which manifests itself as a small ball up to 5 mm in size, filled with pus.Most often, the patient turns to the dentist at the stage of exacerbation of the process, when the formation of the granuloma is complete. Granuloma is a source of spread of infection, destruction of healthy tooth tissues, progressing, can cause severe complications.

The name “cyst” is translated from Greek as “bubble”. A dental cyst is a pathological process in which a cavity with a dense wall, filled with pus, forms at the root of the tooth. The danger of a cyst is that inflammation can penetrate into the root of the tooth through open canals, and when the cyst ruptures, pus can penetrate into the soft tissues of the neck, face, and even into the blood of a person.

Tooth granuloma, tooth cyst: treatment

It is known that the granuloma and cyst on the root of the tooth will not disappear on their own, and the treatment of the cyst of the tooth with folk remedies will not help get rid of the problem. In the interests of preserving his health, the patient needs to see a specialist as soon as possible.

Until recently, the treatment of tooth granulomas and cysts was reduced to the simplest way – to remove the damaged tooth and clean the gum. In modern dentistry, the tendency to maximize the preservation of existing teeth prevails.Appropriate methods of therapeutic and surgical treatment of tooth cysts and granulomas have appeared. The success of their use depends on a set of factors, but primarily on the experience of the doctor.

If a cyst or a granuloma of a tooth is found by a doctor, treatment must be carried out urgently, since it is necessary to free the root canals from infection as quickly as possible.

Removal of tooth cysts and granulomas can be performed therapeutically. Through the drilled canal of the tooth, the doctor rinses with antiseptics, injects substances that destroy the membrane of the neoplasm and contribute to the restoration of tissue at the site of damage.

The need for surgical intervention arises when the treatment of tooth canals has failed, and re-treatment with a therapeutic method is not effective. Surgical methods for treating granulomas and cysts involve removing the purulent sac through the drainage hole in the gum. After cleaning from pus, the cavity is treated with antiseptics and sutured. When, for technical (or other reasons), one of the roots cannot be cured successfully, the surgeon removes the purulent sac and the problematic root of a multi-rooted tooth.After that, the hole formed at the site of the removed root is filled with the appropriate dental material.

The specialists of the Artis clinic (Kiev) will help the patient to get rid of such problems as “tooth root cyst”, “tooth granuloma”, the symptoms of which are recognized only by an experienced doctor. At the request of the patient, the doctors of the clinic will select the optimal plan for the complex treatment of teeth and oral cavity for a specific situation.

“Supplements Killed My Liver”: What the story of an American who fell for advertising teaches

October 29, 2018

Photo author, Jim McCants

Photo caption,

Jim McKents had a liver transplant after taking dietary supplements

History an American who had to have a liver transplant after taking capsules of green tea extract was again forced to talk about dietary supplements.

When 50-year-old Jim McKents started taking green tea capsules, he hoped that antioxidants would help him avoid a heart attack and lead an active lifestyle until old age. Every day he walked (or ran) several kilometers, tried to lose weight and eat in a balanced way.

“I was prepared for these capsules to be useless and I wasted money. I was willing to take this risk. But I never expected my liver to fail,” McKents says.On the day of his son’s high school graduation, he felt unwell. “You are all yellow,” – said Jim’s wife, and they urgently went to the hospital.

For several days the doctors did tests and could not make a diagnosis. Finally, McKents was told that only a liver transplant would save him. Without a transplant, he would not have lived for a week – the liver completely failed.

By a miraculous coincidence, a donor organ suitable for transplantation was found in one day. Now, four years after the surgery, McKents is experiencing constant abdominal pain, is on constant medication, and has difficulty walking.

He sued Vitacost, a capsule manufacturer. They are sold over the counter – because the supplement is made from tea, it is considered a food product in the United States, not a medicine, and is not certified or tested. “There are no warnings about the possible risks and side effects in the instructions,” says McKents.

Photo author, Getty Images

Experts call the McKents case extremely unusual.

However, about 80 cases of liver disease in people taking granulated green tea are annually recorded in the world: for example, liver and kidney failure occurred in a 17-year-old resident of the Canadian province of Ontario Madeleine Papineau.

Potentially toxic green tea ingredient EGCG (epigallocatechin-3-gallate) may be a hazard. This catechin (a substance with antioxidant properties) is found in abundance in the drink, and its concentration in granules is increased hundreds of times.

“If you just drink reasonable amounts of green tea, you are not in danger,” Gerberg Bonkowski, professor at Wake Forest School of Medicine in North Carolina, told the BBC. He has been studying the effects of green tea supplements on the liver for nearly 20 years.

“Those who take highly concentrated extracts are at risk. Usually they are drunk by those who want to lose weight, and they often do not eat much solid food during this period. We know from animal studies that the body of a hungry, emaciated animal absorbs much more catechins than the body of more well-fed individuals. Another risk factor may be concurrent use of other drugs or alcohol, “- says the professor.

Are dietary supplements harmful?

In the UK, supplements must pass EU safety and health checks.

Regulatory-approved supplements purchased from trusted manufacturers are nearly always safe and come complete with instructions for use, doctors say.

However, as noted by Dr. Wayne Carter of the University of Nottingham, it cannot be argued that food additives cannot be potentially harmful.

For example, if you take a higher dose of such a drug, there may be a health risk.

Photo Credit, Getty Images

Although in many cases excess substances will be excreted from the body, this can pose a threat to the liver, which detoxifies the substances we consume.

“It seems to me that sometimes people think this is good for me, so if I take a large dose, it will make me feel better. But there is a risk,” says Dr. Carter.

Simultaneous intake of many food additives at once can also be dangerous, the expert warns.

Sometimes they can interact with each other: one drug can enhance the effect of another. In other cases, they may contain one or more of the same nutrients, resulting in overdose.

Some of us find it more difficult to efficiently process certain substances, and their effect on the body also depends on this.

“The thing about these drugs is that they are safe for most people, but not for everyone,” adds Carter.

However, if these are the potential risks, what are the health benefits?

Vitamins required and optional

Several dietary supplements are recognized by most experts as universally useful.

The British National Health Service (NHS) recommends that women who wish to become pregnant take folic acid (aka vitamin B9). This recommendation is also valid for pregnant women up to 12 weeks in order to prevent a number of congenital diseases in the child.

The British government said this week that it will discuss with experts the possibility of adding folate to flour.

There are two more vitamins that official medicine strongly recommends: D and K.

Vitamin D supplementation is also recommended for infants, children between the ages of one and four, and people who lack sunlight.

This applies to those who often feel weak or do not leave the house, as well as those who constantly wear closed clothes.

In general, taking vitamin D is recommended for almost any person.

Photo author, Getty Images

Photo caption,

The British Health Service notes that all vitamins and minerals that a person needs are found in healthy food

A lack of vitamin D, which we mainly get from sunlight, can lead to various types of deformations bones: rickets in children and osteomalacia in adults.

“A hundred years ago, most children in London had rickets. However, the situation improved after the children were given vitamin supplements,” says Benjamin Jacobs of the Royal National Orthopedic Hospital.

In addition to vitamin D, almost all young children in Britain are eligible for a vitamin K injection – within the first 24 hours after birth to prevent internal bleeding.

Healthy Nutrition and Supplements

Dr. Jacobs notes that supplements are also recommended for dieters and allergy sufferers.

For example, the UK National Health System (NHS) recommends that vegans consume vitamin B12, which is naturally found only in animal products.

However, for many other supplements, their universal benefits are less clear.

For example, NHS experts say that most people do not need to take vitamin supplements, since all the necessary vitamins and minerals, except for vitamin D, are already in the food if a person eats a balanced diet.

The benefits of fish oil capsules, which are often taken to improve heart or brain function, are also less obvious.

So, scientists came to the conclusion that the statement about the benefits of such capsules for the heart is largely mistaken.

As noted by Sam Jennings, head of the consulting firm Berry Ottaway & Associates Ltd, nutrition is an ever-evolving science with new data emerging all the time.

“Obviously, nutritional supplements cannot be equally beneficial to all people, as it depends on the individual’s characteristics and also on whether the person will benefit from any additional nutrient,” she says.

Dr. Carter advises that you study the findings of scientists regarding a particular supplement before taking it, as well as familiarize yourself with the contraindications.

How to Choose Food e Additive and

• Buy Supplements from Verified Suppliers – Drugs Must Pass Quality Control
• Verify Human Clinical Trials Have Been Made
• Investigate contraindications – for example, people with heart disease should pay attention to the effect of the drug on the functioning of this organ
• Be careful when taking several drugs at the same time
• Adhere to the recommended doses

Source: Dr. Wayne Carter.

Skin cancer, treatment, symptoms – Israeli oncological clinic LISSOD in Kiev, Ukraine

A substance found in the milk thistle plant is capable of killing tumor cells in the skin.

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Vzamodiya cієї speech with chubby clitines, which were given to ultraviolet optimization, was a toothbrush for them.Tse vіdbuvalosya vyroblenya vyroblenya actively form kisnyu, like nnischu live cells. Wonderfully, when they poured into the health of the cells, the shkiri did not spite a toxic effect; navpaki, the speech drifted off the whirring of the whiskey, as if swallowing the shkira.

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Skin cancer is a malignant tumor that affects both men and women in old age (after 60 years). A tumor arises from the epithelium of the skin, usually localized in open areas of the body.Distinguish between squamous and basal cell carcinoma. Sometimes cancer occurs from the appendages of the skin – hair follicles, sebaceous and sweat glands. Skin cancer can develop anywhere, but more often the tumor appears on the face: the corner of the eye, the wings and back of the nose, and the forehead are affected. Often, a tumor is detected in the armpit, on the foot, hand, lower leg.

Basal cell carcinoma (basal cell carcinoma) , as the name indicates, arises from the cells of the basal layer of the skin. The tumor, as a rule, does not spread, it grows slowly. Basal cell carcinoma makes up 70–75% of skin cancers, practically does not give metastases.

Squamous cell carcinoma develops in the superficial cells of the skin, which, if not treated, can invade other organs. Basically, it metastasizes by the lymphogenous pathway.

Diagnostics

In LISOD, the diagnosis of skin cancer is made on the basis of a thorough examination of a suspicious tumor.The examination is carried out using a magnifying glass. The main method for recognizing skin cancer is a biopsy with excision of a sectoral piece with the capture of healthy tissue along the edge. Less often, a cytological examination of prints from a tumor or punctate from dense areas of an ulcer is performed. We send all tissue samples to pathohistological laboratories with an international certificate, which are located in Germany and Israel.

To exclude metastases in internal organs, LISOD uses ultrasound (ultrasound), computed tomography (CT), and radiography.

Modern research method PET-CT is prescribed to exclude systemic spread in skin lymphomas, as well as to exclude a primary malignant tumor in paraneoplastic processes, such as dermatomyositis.

Treatment

Consultants of the LISOD Information Service will provide you with full information on the diagnosis and treatment of this type of cancer:

• 0-800-500-110 (toll-free for calls to
  from landline telephones within Ukraine)
• or +38 044 520 94 00 – daily
  from 08:00 to 20:00.

A treatment plan at LISOD is developed by a consultation of specialists at an interdisciplinary oncological conference individually for each patient, taking into account the type and size of the tumor, age, general health. It should be noted that almost 90% of patients with both squamous and basal cell carcinomas are completely cured.

Radiation therapy is the most commonly prescribed treatment for skin cancer. Close-focus X-ray therapy is used; for common forms, it is used in combination with external radiation therapy.

In cases of low sensitivity to radiation therapy or highly advanced cancer, surgical treatment using skin grafting is used to close postoperative defects. Surgery to remove lymph nodes is performed in the presence of metastases in regional lymph nodes.

Rarely, for skin cancer, chemotherapy is used with the use of special ointments, which include cytostatic drugs.

Symptoms

Both squamous cell carcinoma and basal cell carcinoma can manifest themselves in different forms.You may notice a slight bump on the skin that looks like a smooth or grainy, and sometimes waxy, build-up. Often a scab forms, the build-up bleeds. A red, flat spot may appear as a scaly scab. Characteristic of a cancerous ulcer are roller-like, raised flat edges, the bottom of the ulcer is of a dirty gray color. Sometimes there is a red, dense swelling on the skin, usually growing slowly and without pain. Such a tumor can appear anywhere on the body, but more often it affects open areas – especially the neck and face.Wart-like squamous cell carcinomas are found on the lower legs, hands, and forearms.

If you notice that some unusual formation has appeared on the skin, which has not disappeared within a month, be sure to contact your oncologist.

Precancerous diseases

Cancer often develops as a result of previous skin changes. Obligate precancerous diseases (early oncological pathology that degenerates into cancer) are Bowen’s disease, xeroderma pigmentosa, Keir’s erythroplasia, and Paget’s disease.Ulcers, long-term non-healing wounds, inflammatory and chronic dystrophic processes are referred to as facultative precancers (pathology that does not always turn into a malignant state, but requires careful observation).

Risk factors

1. The main cause of skin cancer is sun exposure. People who are exposed to ultraviolet radiation for a long time are at greater risk of developing the disease.Most often, it is in the open areas of the skin (head and neck area) that the tumor is localized.
2. Professional activities associated with regular contact with tar, tar, soot, arsenic can also lead to the development of skin cancer.
3. Tumor may result from prolonged exposure to heat or ionizing radiation.
4. Sometimes the disease develops against the background of scars after mechanical damage to the skin.
5. Rarely, but hereditary conditions exist that lead to skin cancer.

Prevention

To prevent the development of skin cancer, we recommend the following.

• Protect neck and face from sunlight. This is especially important for those with fair skin and the elderly.
• Avoid dry skin by regularly applying nourishing creams.
• Observe personal hygiene measures when using household cleaning products.
• Observe all necessary safety rules if your work involves the use of chemicals (pharmaceuticals, nitric acid, benzene, pesticides, etc.).
• Timely treat ulcers, lupus, chronic precancerous dyskeratosis.
• Protect scars and scars from mechanical damage.

Questions and Answers

The section publishes questions from patients and the answers of our specialists.Each person’s question concerns a specific problem related to their illness. The patients are answered by Israeli clinical oncologists and the chief physician of LISOD, MD, professor Alla Vinnitskaya.

Experts’ answers are based on knowledge of the principles of evidence-based medicine and professional experience. The answers correspond exclusively to the information provided, are for informational purposes only and do not constitute a medical recommendation.

The main purpose of section is to provide information to the patient and family so that they can decide together with the treating physician about the type of treatment.The proposed treatment tactics may differ from the principles stated in the answers of our specialists. Feel free to ask your doctor about the reasons for the differences. You need to make sure you are getting the right treatment.

Hello.I was diagnosed with basal cell carcinoma of the lower eyelid, the outer corner of the eye. A year after the DTK, it began to grow again. Now its size is 3×3 mm. Is it possible to administer radiation therapy in a way that does not hurt the eye?

It would be nice to see exactly where it is located, but, in principle, it is quite possible.Irradiation can be superficial, not penetrating deeply, but sufficient to treat a skin tumor (X-ray therapy or electron irradiation), sometimes, for greater reliability, a special plate is inserted under the eyelid at the time of treatment.

Hello, dear Grigory Borisovich! Your opinion is very important to me.A scab (2 mm in diameter) appeared on my mother’s (72 y.) Nose in the fall near the corner of her eye. He then disappeared, then reappeared, but did not increase in size. On January 19, 2011, we did a scraping at the oncology center. The results of the analysis were not shown to us, but they said in words that the diagnosis was as follows – SA of the skin of the inner corner of the left eye, elements of the basal cellular SA, and you either need to cauterize with a laser or irradiate. But here’s the paradox. After scraping (and they knocked off that place well), the newly appeared scab fell away and for the third month there is nothing in this place – no scab, no wobbling, everything is clean.Question:
1. Is skin cancer necessarily accompanied by some kind of non-healing wound or can it exist without any visual manifestations?
2. Or maybe it was just an infected wound? After all, after scraping them, I washed this place well with a solution of chlorhexidine bigluconate for several days and after that everything healed.
3. So what should we do?

Valentina, firstly, you should make a revision of the histological preparations to make sure that we are really talking about basal cell carcinoma (it can be carried out in our laboratories in Israel or Germany).It is possible that the biopsy performed (“scraping”) turned out to be excisional, i.e. the tumor was completely removed, which explains the absence of signs of disease on the skin. I think we can observe. Only carefully, since basaliomas are very prone to recurrence, if not completely removed.

Hello! My father is 72 years old, diagnosed with basalioma of the upper eyelid of the right eye, and prescribed radiotherapy.Basal cell carcinoma seems to be the most harmless skin cancer, do you think it is necessary to do radiation at this age and what side effects can occur after radiation (eye burns or loss of vision)? And a month and a half ago he had an operation on his left eye for cataract, will the irradiation affect the artificial lens? Thank you in advance for your answer!

It is necessary to treat unequivocally regardless of age.Basaliliomas give distant metastases in only 2% of cases, but they are quite aggressive in terms of local spread: relapses after incomplete removal, deep infiltration of underlying tissues, etc. If the surgical intervention is not associated with a significant cosmetic defect, then it is preferable in this particular case (preferably according to Moh – with intraoperative histological examination of the surgical edges).

Sinus lifting | Dentistry Ⓜ️ Mitino

Sinus lift is a surgical operation in which the doctor builds up the bone tissue of the upper jaw.This procedure is performed before implantation if the patient’s maxillary bone is atrophied. In this case, the doctor cannot restore the dentition, since there is nowhere to install the implants.

During sinus lifting, the floor of the patient’s maxillary sinus is raised above the initial level with the help of certain procedures. After a short rehabilitation period, the patient regains chewing functions and can fully eat.

Bone augmentation is a serious surgical intervention that requires high qualifications and skill of the surgeon.But with the correct procedure, complications are unlikely, and the rehabilitation period is only 3-4 weeks.

What is sinus lift

Not every patient immediately after tooth extraction thinks about installing an implant. Sometimes the decision on prosthetics can be made after several years. During this time, the bone tissue of the jaw “relaxes” – it loses volume and density, so it is already problematic to install an implant. The jaw tissue can become thinner due to:

• gum and periodontal inflammation;
• the occurrence of cysts or inflammation of the roots of the teeth or sinuses;
• injuries to the jaw;
• osteoporosis;
• anatomical features of the jaw structure.

To install implants, a certain amount of bone tissue is required. To build it up on the upper jaw, the doctor uses the space of the maxillary sinuses. This is possible because the floor of the maxillary sinus is a thin bony wall and sits directly above the upper teeth.

The lining of the maxillary sinuses is quite dense, and during the operation, the doctor lifts it in one way or another, depending on the type of procedure. And he fills the resulting space with bone synthetic material.

The volume of the injected material allows you to reliably install an implant with a post length of up to 10 mm and not injure the maxillary sinus tissue.

The essence and principle of operation of the procedure

Sinus lifting is performed only on the upper jaw. It is impossible to apply the method on the lower jaw, because the maxillary sinuses are not there and it is a solid bone.

However, it is the upper jaw that is thinning much faster than the lower one.

During the operation, a small incision is made on the jaw at the site of the bone grafting. The bottom of the maxillary cavity is carefully displaced to form the space necessary for the introduction of the bone graft substitute. Thus, sinus lifting means exactly “raising the sinus.”

The operation is performed under local or general anesthesia.

Indications for use

Sinus lift can be recommended for patients with bone atrophy of the upper jaw.

Indications for surgery:

• bone height less than 8 mm;
• severe bone destruction after tooth extraction;
• congenital anatomical features of the structure of the upper jaw. For example, when the maxillary sinus is located very close to the oral cavity or the alveolar bay is deep enough.

Types of sinus lifting

The doctor chooses the type of operation depending on the individual characteristics and condition of the patient.Currently, the main techniques are:

1. Open (lateral) sinus lift. The side wall of the maxillary sinus is used for access. This is a complex procedure, but it provides the most significant bone growth.
2. Closed (vertical, transcrestal) method. Access for manipulation is through the implant well. The operation is more gentle. It is more often practiced in cases where the height of the bone tissue on the patient’s jaw does not exceed 7-8 cm.
3. Balloon. The technique is especially relevant for patients with insufficient gum bone height (3-4 mm). The augmentation takes place through the socket of the implant. The name of the method comes from the type of devices that the doctor uses to lift the floor of the maxillary sinus. Namely – a catheter with a balloon. In this case, the artificial tooth can be placed immediately after sinus lifting. An additional visit to the doctor is not required, the operation is minimally invasive, patients tolerate it well.
4. Ultrasonic BIO. The newest method of sinus lifting, using a bone substitute of natural origin. Differs in a gentle way of affecting the body.

How is the operation

The operation takes no more than 20 minutes. If the sinus lift is performed in a closed way, the doctor can install an implant during the operation. With an open procedure, implantation is possible after the gums have completely healed.

With an open method of sinus lifting, the operation consists of the following stages:

• Making an incision in the gum and bone;
• formation of the site for the introduction of the implant;
• soft rise of the maxillary sinus floor;
• filling the cavity with bone composition;
• suture.

The sequence of actions for closed sinus lifting:

• Creation of a cylindrical hole in the gum and jaw bone;
• displacement of a part of the base of the maxillary sinus;
• filling the space with granular material;
• implant placement – if necessary at this stage.

Balloon sinus lifting is performed in the following sequence:

• with a special thin cutter form a place for the installation of the implant.In this case, the instrument passes the soft tissues of the mucous membrane and the bone to the base of the maxillary cavity, not reaching 1 mm to its bottom;
• a catheter and a balloon attached to it are inserted into the opening;
• the doctor gradually fills the balloon with a contrast agent, it increases in size and raises the sinus membrane of the upper jaw. This forms a bed for the introduction of bone substance;
• , a bone substance is inserted into the cavity and the implant is immediately implanted.

Stages of ultrasound sinus lift:

• taking blood from a patient.In this case, the laboratory assistant releases substances that are responsible for the regeneration processes;
• preparation of a concentrated substance that will be used in sinus lifting. Active blood cells isolated at the previous stage are introduced into its composition;
• dissection of the upper gum and preparation of the access channel to the base of the maxillary sinus;
• implantation of a bone substitute and an active substance from the patient’s blood cells;
• implant placement.

Repeated sinus lift

After the gum has healed and the injected bone substance securely anchors the implant, the next sinus lift operation can be performed. As a rule, at least six months pass between two operations, and possibly longer, depending on the patient’s condition.

Before the decision on repeated sinus lifting is made, the patient must undergo X-ray diagnostics of the maxillary cavities. So the doctor will make sure that there are no pathologies in the area of ​​the upcoming operation, and will also assess the thickness of the bone mass.

In addition, the surgeon needs to assess the bone structure of the alveolar processes in the upper jaw.

Materials used for sinus lifting

Several types of bone grafting material are used during the operation. The type of operation prescribed will depend on which composition the doctor will use.

The main types of material for gum augmentation:

• autograft.It is made on the basis of a particle of bone tissue taken from a patient. Typically, the sample is taken from the bone of the lower jaw;
• allograft. This bone material is taken from the corpse and prepared in a special way for the operation;
• xenograft. Material prepared from the intercellular substance of bovine bone. It does not contain organic matter and is completely safe;
• alloplant. A synthesized substance similar to human bone in external and radiological characteristics.It takes a little longer to take root than what is prepared from natural biological material.

Contraindications for gingival augmentation

It is undesirable to perform the operation on patients with insufficient oral hygiene, tartar and oral diseases. It is not always possible to carry out a sinus lift during pregnancy.

Operation is absolutely contraindicated in the following cases:

• for any malignant diseases;
• conditions caused by immunodeficiency;
• drug and alcohol addiction;
• mental disorders;
• diseases causing blood disorders;
• heart disease.

Sinus lifting is strictly prohibited:

• with sinusitis and sinusitis;
• polyps located at the site of surgery;
• incorrect location of the maxillary sinuses;
• increased bone fragility;
• in the event that operations have already been performed on the maxillary sinuses.

Complications

Complications of sinus lift are rare. They may be associated with the patient’s existing ENT diseases:

• acute or chronic sinusitis;
• edema and inflammation of the maxillary sinuses;
• puncture or rupture of the mucous membrane of the maxillary cavity;
• chronic rhinitis;
• violation of the outflow of fluid from the maxillary sinus;
• bleeding from the nose or from the site of surgery.

Sinus lift surgery is not easy and absolutely safe. But if it was performed by an experienced surgeon in accordance with all the rules and regulations, undesirable consequences will not arise.

Use of autogenous bone marrow cells adhered to hydroxyapatite in the treatment of bone cysts in adult patients

Use of autogenous bone marrow cells adhered to hydroxyapatite in the treatment of bone cysts in adult patients

Treatment of large-volume bone cysts is always associated with a deficiency of plastic material, as well as dystrophic changes occurring in the bone tissue adjacent to the cyst.Some types of bone cysts are of tumor origin (osteoblastoclastoma, giant cell tumor), arise as a result of the malformation of the vasculature (aneurysmal) or fibrous dysplasia. The progression of a bone cyst leads to thinning, as a result of death or increased resorption of bone tissue, and a pathological fracture. Since most bone cysts (with the exception of osteoblast-clastoma) are asymptomatic and appear only with a pathological fracture, then treatment is currently reduced to immobilization and subsequent, after 4-6 months.operations [1-3, 6].

Among the surgical methods of treatment are used periodic decompression (aneurysmal cysts) and curettage of the cyst cavity (fibrous dysplasia) in combination with chemotherapy (osteoblastoclastoma) in the hope of active reparative osteogenesis [1, 3, 6]. To fill the cavity of the cyst, such plastic materials as: demineralized bone matrix, collagen sponges, hydroxyapatite ceramics, in the form of three-dimensional structures or granules, etc. are actively used. surrounding the cyst, and can lead to a relapse of the disease.The use of cellular material (native blood, unfractionated bone marrow) significantly accelerates and improves the processes of bone regeneration, due to the induction and direct influence of cells introduced together with the biomaterial. These techniques are used in orthopedic traumatology in children with aneurysmal bone cysts [4, 5].

The development of cellular technologies in an orthopedic clinic can offer a standardized technique for replenishing bone tissue deficiency using multipotent mesenchymal stromal cells (MMSC) of the bone marrow and their osteoblastic derivatives.In Artificial Organs magazine, Japanese authors cite
description of several clinical observations of the use of a similar technique in tissue-engineered reconstruction of large bone cysts.

Three patients (with aneurysmal bone cyst, osteoblastoclastoma, and fibrous dysplasia) underwent bone marrow harvesting, from which MMSCs were isolated by culture adhesion to plastic. Fibroblast-like cells having the phenotype CD14- / CD34- / CD45- / CD13 + / CD29 + / CD90 + were expanded in culture for 2 weeks.Then MMSCs were placed on porous granular hydroxyapatite and blocks of 4 * 4 * 4 mm in the medium inducing osteogenesis, and cultured for another 2 weeks. The authors do not indicate a change in the phenotype of MMSC after osteogenic stimulation in a differentiation medium, but they demonstrate ectopic bone formation from a construct implanted in mice. After fabrication, a mixture of blocks and granules with cells was placed in the cavities of the cysts, subjected to preliminary curettage.

After a considerable time after the operation (the first patient – 40 months., second – 43 months, third – 29 months), instrumental methods (computed tomography and X-ray examination) showed complete integration of the transplanted structures and the absence of any reactions and relapses from the surrounding tissue. No adverse reactions associated with construct transplantation were observed. These findings allowed the authors to interpret the study results as good.

It should be said that hydroxyapatite ceramics is not bioresorbable and does not provide complete organotypic regeneration of bone tissue.In this regard, the authors do not recommend this material for active young people and overweight patients due to the high risk of fractures at the transplantation site. It should also be added that the use of this technique in patients with fibrous dysplasia is justified only with bulky cysts, which is not so common, since the reparative potential of the bone tissue surrounding the cyst in most cases is sufficient for spontaneous closure of the defect even without the use of plastic materials. which cannot be said about aneurysmal cysts.

As an alternative, the researchers propose the use of biodegradable ceramics based on tri-calcium phosphate, which would increase the strength of the newly formed tissue.
The proposed method has shown its safety and feasibility. Future studies will allow modification of the method and confirm the clinical efficacy of the method.

90,000 Against free radicals and insomnia: all about the benefits and dangers of chicory

https://ria.ru/20210215/tsikoriy-1597599210.html

Against free radicals and insomnia: all about the benefits and dangers of chicory

Against free radicals and insomnia: all about the benefits and dangers of chicory – RIA Novosti, 02/15/2021

Against free radicals and insomnia: all about the benefits and dangers of chicory

Chicory is an unpretentious plant that grows in meadows throughout Russia and has a lot of useful properties. For what the drink from its root is valued – in … RIA Novosti, 15.02.2021

2021-02-15T20: 03

2021-02-15T20: 03

2021-02-15T20: 03

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russia

healthy lifestyle

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MOSCOW, Feb 15 – RIA Novosti. Chicory is an unpretentious plant that grows in meadows throughout Russia and has a lot of useful properties. For what the drink from its root is valued – in the material of RIA Novosti. Homeland and history of chicory This perennial herb with blue flowers from the Astrovye family grows like a weed in fields, forests and mountainous areas throughout Russia. The coast of the Mediterranean Sea is considered the homeland of chicory.The healing properties of the plant are mentioned in the ancient Egyptian papyrus of Ebers (XVI century BC), and in the works of ancient doctors and scientists (Theophrastus, Dioscorides, Pliny the Elder). It was used to improve digestion and treat joint diseases. In Russia, the cultivation of chicory and its industrial use began in the time of Peter I. According to one of the versions, the emperor brought it from Holland. The roots of the plant are used to prepare the drink. They are crushed and fried, and then processed to create the final product.In our country, chicory was considered a symbol of modesty, moderation, frugality and loyalty. He was called “the bride of the sun” because of the ability of flowers to turn in the direction of the movement of the luminary. Why is chicory useful? The plant contains many useful substances: vitamins A, C, E, B1, B2, B5, B6, K, as well as potassium, calcium, iron , selenium, beta-carotene. Thanks to them, chicory increases immunity, protects the body from the penetration of free radicals, reduces the risk of developing cancer and improves the functioning of the cardiovascular system.Unlike coffee, chicory does not contain caffeine, the consumption of which many experts advise to limit the consumption of people with heart disease. Also, chicory is useful for enhancing brain activity. In addition, it helps in the fight against insomnia. You can drink chicory during pregnancy, as well as nursing mothers, but in reasonable quantities. Before use, it is better to consult a specialist. Can it be harmful In addition to what chicory is useful for, it is worth knowing to whom it is contraindicated. For example, a product can cause an allergic reaction, therefore, when using it for the first time, you should be careful, especially for allergy sufferers.It can also harm people suffering from varicose veins and gallstone disease. The use of chicory may have contraindications for hypertension, hemorrhoids, stomach ulcers, acute renal failure, arterial hypotension, acute liver diseases. In these cases, it is better to consult a doctor before using the product. The product is also actively used in dietetics.Use in culinary From a drink based on chicory, cocktails are created, glazed, added to natural coffee. There is also a chicory salad. The herb is like a small head of Chinese cabbage. It is used to make salads, hot dishes, as well as snacks and soups.Supernergizer Cocktail Ingredients: Preparation: Squeeze juice from an orange, pour dried apricots over it and leave for 30 minutes. Boil the chicory with three tablespoons of boiling water and mix with condensed milk. Whisk all the ingredients until smooth, pour into two glasses and garnish with orange slices.Chicory and avocado salad with Roquefort cheese dressing Ingredients: Preparation: Boil the hard-boiled egg and cut into thin slices. Grind the avocado pulp. Cut the cherry tomatoes into halves, bell peppers into strips, chicory into small pieces. To prepare the sauce, mix the yogurt, sour cream and vinegar. Add chopped roquefort and chopped parsley to them. Combine all ingredients and season with sauce. Salt, pepper and serve. How to choose and store When choosing a powder product, it is important to pay attention that there are no barley flour, ground oats or rye among the ingredients.At the same time, ginger, rosehip, honey, lemon are allowed in the composition. Metallized packaging is preferable, since chicory does not like moisture. There should be no hard lumps inside, which are a sign of a poor-quality product. If the product emits a pungent odor, then flavors have been added to the composition. Store powdered chicory at home in a dry place, away from direct sunlight. Shelf life is 12 to 18 months. Liquid chicory retains the highest concentration of nutrients.The shelf life of the product in liquid form is 12 months. How to use correctly The maximum daily dose of chicory powder is no more than 1.5-2 tablespoons of crushed root. In this case, 1 teaspoon of the powder product is comparable to half a teaspoon of liquid concentrate. Prepare the drink as follows: pour a teaspoon of the powder with hot water in an amount of 200 ml and stir until completely dissolved. It is recommended to drink the drink no more than twice a day.

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MOSCOW, Feb 15 – RIA Novosti. Chicory is an unpretentious plant that grows in meadows throughout Russia and has a lot of useful properties. For what the drink from its root is valued – in the material of RIA Novosti.

Homeland and history of chicory

This perennial herb with blue flowers from the Astrovye family grows as a weed in fields, forests and mountainous areas throughout Russia.

The shores of the Mediterranean Sea are considered the birthplace of chicory. The healing properties of the plant are also mentioned in the ancient Egyptian papyrus of Ebers (XVI century BC).BC), and in the works of ancient doctors and scientists (Theophrastus, Dioscorides, Pliny the Elder). It was used to improve digestion and treat joint diseases. In Russia, the cultural cultivation of chicory and its industrial use began in the time of Peter I. According to one version, the emperor brought it from Holland.

The roots of the plant are used to prepare the drink. They are crushed and fried, and then processed to create the final product.

In our country, chicory was considered a symbol of modesty, moderation, frugality and loyalty.He was called “the bride of the sun” because of the ability of flowers to turn in the direction of the movement of the sun.

Why chicory is useful

The plant contains many useful substances: vitamins A, C, E, B1, B2, B5, B6, K, as well as potassium, calcium, iron, selenium, beta-carotene. Thanks to them, chicory increases immunity, protects the body from the penetration of free radicals, reduces the risk of developing cancer and improves the functioning of the cardiovascular system. Unlike coffee, chicory does not contain caffeine, which many experts advise to limit the consumption of people with heart disease.

– The drink has a beneficial effect on the intestinal microflora, significantly reduces the risk of inflammatory processes. Inulin promotes the growth of beneficial bifidobacteria and the absorption of calcium, – told nutritionist Oleg Klochkov.

Also, the benefit of chicory is to enhance brain activity. In addition, it helps in the fight against insomnia.

Chicory during pregnancy, as well as nursing mothers, you can drink, but in reasonable quantities. It is better to consult a specialist before use.

July 5, 2019, 11:21 a.m. Said on air Is instant coffee safe? Dealing with a dietitian “Roskontrol” assessed the quality of granulated instant coffee. All tested brands are recognized as safe, but three of them have comments. Nutritionist Rimma Moysenko told Sputnik which coffee should be preferred.

Can it be harmful

In addition to what chicory is useful for, it is worth knowing to whom it is contraindicated. For example, a product can cause an allergic reaction, therefore, when using it for the first time, you should be careful, especially for allergy sufferers.

It can also harm people suffering from varicose veins and gallstone disease. The use of chicory may have contraindications for hypertension, hemorrhoids, stomach ulcers, acute renal failure, arterial hypotension, acute liver diseases. In these cases, it is best to consult a doctor before using the product.

As used in medicine

In medicine, the beneficial properties of chicory are used in combination with the therapy prescribed by a doctor.The product is also actively used in dietetics.

– Substances contained in the drink are useful for patients with diabetes and obesity. Chicory helps to lower sugar and bad cholesterol in the body, which is very important for diabetics. Also, a drink made from chicory, when consumed regularly, normalizes the digestive system and promotes faster satiety. That is why it is recommended to use chicory for weight loss, – emphasized Oleg Klochkov.

November 26, 2020, 15:24

11 products that accelerate metabolism are named

Application in culinary

Cocktails are made from a drink based on chicory, made a glaze, added to natural coffee.

There is also a salad chicory. The herb is like a small head of Chinese cabbage. Salads, hot dishes, as well as snacks and soups are made from it.

Super Energizer Cocktail

• –

  soy, almond or coconut milk – 300 milliliters;

• –

  dried apricots – 6 pieces;

• –

  orange – 1 piece + two slices for decoration;

• –

  chicory powder – 1 teaspoon;

• –

  condensed milk – 4 tablespoons;

• –

  cinnamon – one pinch;

• –

  ground star anise – one pinch.

Preparation:

Squeeze juice from the orange, pour dried apricots over them and leave for 30 minutes. Brew chicory with three tablespoons of boiling water and mix with condensed milk.

Beat all ingredients until smooth, pour into two glasses and garnish with orange slices.

Salad with chicory and avocado with Roquefort cheese dressing

• –

  chicken egg – 1 piece;

• –

  avocado – 1 piece;

• –

  cherry tomatoes – 10 pieces;

• –

  sweet pepper – 1 piece;

• –

  chicory salad – 2 heads of cabbage;

• –

  yogurt – 3.5 tablespoons;

• –

  sour cream – 2.5 tablespoons;

• –

  vinegar – 2 tablespoons;

• –

  parsley – 1 bunch;

• –

  Roquefort cheese – 50 grams;

• –

  salt and ground black pepper to taste.

Preparation:

Boil the hard-boiled egg and cut into thin slices. Grind the avocado pulp. Cut cherry tomatoes into halves, bell peppers – into strips, chicory – into small pieces.

To prepare the sauce, stir together the yoghurt, sour cream and vinegar. Add chopped roquefort and chopped parsley to them.

Combine all ingredients and season with sauce. Season with salt, pepper and serve.

September 3, 2020, 15:31

Named an easy way to check the quality of instant coffee

How to choose and store

When choosing a powder product, it is important to pay attention that there are no barley flour, ground oats or rye among the ingredients.At the same time, ginger, rosehip, honey, lemon are allowed in the composition.

Metallized packaging is preferable, as chicory does not like moisture. There should be no hard lumps inside, which are a sign of a poor-quality product. If a pungent odor is emitted from the product, then flavors have been added to the composition.

Store powdered chicory at home in a dry place, away from direct sunlight. The shelf life is from 12 to 18 months.

Liquid chicory retains the highest concentration of nutrients.The shelf life of the product in liquid form is 12 months.

January 16, 2020, 15:18

The doctor explained whether it is worth replacing familiar products with analogues

How to use correctly

The maximum daily dose of chicory powder is no more than 1.5-2 tablespoons of crushed root. Moreover, 1 teaspoon of powder product is comparable to half a teaspoon of liquid concentrate.

Prepare the drink as follows: pour a teaspoon of the powder with hot water in an amount of 200 ml and stir until completely dissolved.

– In the process of losing weight, of course, it is worth drinking chicory without sugar and cream, but the addition of natural sweeteners and low-fat milk is allowed. In combination with ginger, the drink helps to strengthen the heart muscle, vasodilation. And to maintain the digestive function, chicory is especially useful in combination with rose hips, the expert noted.

It is recommended to drink the drink no more than twice a day.

6 December 2019, 02:00

Green or Black? Which tea suits Russians more About the ideal choice of tea for residents of Russia, the expert on this drink Elizaveta Tikhonova told Sputnik radio.

Teratoma | Cancer | Pathology

Large intestine Teratoma.

Definition / General:

Rare in the colon or rectum

Generally mature
Excision is the treatment for all cases of mature cystic teratoma reported to date

Case reports:

30-year-old male with mature cystic teratoma (dermoid cyst) in the cecum (Arch Pathol Lab Med 2002; 126: 97)
41-year-old female with malignant teratoma associated with ulcerative colitis (Virchows Arch A Pathol Anat Histopathol 1987; 411: 61)
76-year-old woman with “hairy polyp” (Endoscopy 1989; 21: 148)

Gross description:

Dermoid cyst
Single-chamber cyst with thin uniform walls and a smooth lining, contains a brown-white cheese material that exfoliates in layers
May contain hair or teeth

Micro Description:

Dermoid cyst
Cyst covered with keratinized squamous epithelium with granular tissue
Cyst wall may contain sebaceous glands and other accessory structures
Variable fibrosis and smooth muscle
No endodermal or mesodermal elements; No immature elements or atypia

Micro-images:

Figure 1.A CT scan of the abdominal cavity shows a short, well-demarcated, low density (arrow). The mass is separated from the right kidney. Note the close relationship between mass and the ascending colon.

Figure 2. Gross photograph of an 8 cm unvulcanized cyst showing a white raw cyst content. (The outer surface is painted black.)

Figure 3. The cyst is lined with keratinizing stratified squamous epithelium with a granular layer (hematoxylin-eosin, original magnification × 100).

Figure 4. Wall glands were identified in the cyst wall (Hematoxylin-eosin, x200 baseline magnification).

.