Case Report: Punch Excision of an Epidermal Inclusion Cyst in a 39-Year-Old Male | Village Dermatology Katy & Houston, TX
by: Caroline Vaughn
Introduction
Epidermal inclusion cysts are among the most common benign skin lesions seen in dermatology. While often harmless, patients may choose removal for cosmetic, diagnostic, or preventive reasons. At Village Dermatology in Katy and Houston, Texas, we provide expert evaluation and removal of cysts with safe, in-office procedures. This case highlights a 39-year-old male who presented with a cyst on his upper back.
Patient Presentation
The patient, a 39-year-old male, reported a cyst on his right upper back/superior thoracic spine that had been present for nearly a year. The lesion was enlarging, moderate in severity, and persistent. The patient denied pain, drainage, or episodes of inflammation.
Examination
Focused exam of the back revealed:
Well-nourished, well-appearing male
Epidermal inclusion cyst measuring 1.6 x 1.2 cm on the superior thoracic spine
No erythema, tenderness, or drainage at the time of evaluation
Diagnosis
Epidermal Inclusion Cyst (L72.8)
Associated cutaneous inflammation
Management & Procedure
Counseling
The patient was reassured that epidermal inclusion cysts are benign sacs containing keratin and do not require treatment unless inflamed, painful, or cosmetically concerning. He elected for removal. Risks, benefits, and alternatives were reviewed, including possible infection, recurrence, or scarring.
Punch Excision
Location: Superior thoracic spine
Size: 1.6 x 1.2 cm
Anesthesia: Local infiltration with 1% lidocaine with epinephrine
Procedure:
Skin prepped with Betadine and draped
A 4 mm punch tool was used to excise the cyst opening
Blunt dissection performed to remove cyst contents and capsule
Hemostasis achieved with electrocautery
Simple interrupted closure with 4-0 nylon sutures
Petrolatum and sterile dressing applied
Estimated blood loss: Minimal
Complications: None
Post-Procedure Care
The patient was instructed to:
Avoid heavy lifting, exercise, or swimming for 14 days
Keep the wound clean and apply petrolatum as directed
Return for suture removal in 14 days
Contact the office for fever, bleeding, severe pain, or signs of infection
Conclusion
This case demonstrates the successful punch excision of a benign epidermal inclusion cyst in an adult male patient. At Village Dermatology in Katy and Houston, TX, our dermatologists specialize in safe removal of cysts, moles, and skin growths, ensuring optimal cosmetic outcomes and patient peace of mind.
