Abstract
Inflamed epidermal cysts have traditionally been managed using a 2-stage approach based on the assumption that inflammation indicates active infection. However, emerging evidence suggests that sterile inflammation resulting from keratin-induced foreign body reactions may be more common than actual infections. This study aimed to evaluate the microbiological profiles and clinical outcomes of immediate excision and primary closure of inflamed and non-inflamed epidermal cysts without the use of routine antibiotic therapy. This retrospective cohort study was conducted using prospectively collected clinical data between May 2023 and May 2025. Adult patients with clinically suspected epidermal cysts underwent immediate surgical excision and primary closure regardless of inflammation status. Intraoperative bacterial cultures were performed, and antibiotics were administered only when clinically indicated. Among 444 histologically confirmed cases of epidermal cysts, 254 (62.4%) were classified as inflamed. Positive bacterial cultures were more common in the inflamed cyst group than in the non-inflamed cyst group (P = .003); however, most isolates were skin commensals. Staphylococcus aureus was isolated from 26 cases (24 inflamed and 2 non-inflamed), with methicillin-resistant S aureus detected in 13 of the 24 inflamed cases. The overall complication rate was 2.5%, with no significant difference between the groups (3.1% vs 1.3%, P = .332). Only 1 immunosuppressed patient harboring methicillin-resistant S aureus required reoperation. Immediate surgical excision with primary closure is a safe and effective treatment for both inflamed and non-inflamed epidermal cysts. Routine antibiotic therapy and delayed surgery may not be necessary in most cases, supporting a simplified, single-stage management approach.
Keywords: epidermal cyst, inflammation, methicillin-resistant Staphylococcus aureus (MRSA), primary closure
1. Introduction
Epidermal cysts, also known as epidermoid or epidermal inclusion cysts, are common benign cutaneous lesions that originate from the proliferation of epidermal cells within the dermis. These lesions typically present as slow-growing, mobile, and non-tender subcutaneous nodules, most frequently found on the face, neck, trunk, and scalp. Although generally asymptomatic, epidermal cysts may rupture or become secondarily infected, resulting in acute inflammation and abscess formation, conditions that often lead patients to seek medical attention.[1,2]
Treatment strategies for epidermal cysts vary depending on the presence or absence of inflammation. Non-inflamed cysts are typically treated via surgical excision and primary closure, whereas inflamed cysts are traditionally managed using a 2-stage approach: initial conservative treatment – including antibiotics and/or incision and drainage – followed by delayed excision.[3–5] This approach is intended to address concerns that operating during acute inflammation may increase the risk of wound complications, such as infection and dehiscence.[6]
The previously described treatment approaches are largely influenced by assumptions about the underlying microbiology of epidermal cysts. Skin commensals, most notably Staphylococcus aureus and coagulase-negative staphylococci (CoNS), are frequently isolated from both inflamed and non-inflamed cysts.[3,7] However, whether the presence of bacteria in inflamed cysts reflects an actual infection requiring antibiotic treatment or merely colonization within a sterile foreign body-type inflammatory response remains unclear.[8] The increasing prevalence of antibiotic-resistant strains, particularly methicillin-resistant S aureus (MRSA) and methicillin-resistant CoNS (MRCoNS), further complicates decision-making for empirical antibiotic therapy.[9–12]
Recent studies have challenged the conventional 2-stage approach for treating inflamed epidermal cysts, suggesting that immediate surgical excision with primary closure may be a viable alternative.[13–15] This approach could reduce the treatment duration and minimize unnecessary antibiotic use.[16] However, the microbiological characteristics of inflamed versus non-inflamed epidermal cysts remain poorly defined, and the clinical efficacy of immediate excision without routine antibiotic therapy has not been adequately evaluated. In this study, we compared the microbiological profiles, including the prevalence of antibiotic-resistant Staphylococcus species, between inflamed and non-inflamed epidermal cysts and assessed the clinical outcomes of single-stage surgical excision with primary closure performed without routine antibiotic use in both groups.
2. Methods
2.1. Study design
This retrospective cohort study was a retrospective analysis of prospectively collected data designed to compare the microbiological characteristics and clinical outcomes of epidermal cysts according to inflammatory status in patients undergoing single-stage minimal excision with primary closure without routine antibiotic therapy. From May 2023 to May 2025, adult patients clinically suspected of having epidermal cysts were recruited from Kangnam Sacred Heart and Hwahong Hospitals. All patients underwent immediate surgical excision and primary closure, regardless of lesion size or inflammatory status. Routine intraoperative bacterial cultures were performed. Antibiotics were not administered preoperatively or postoperatively unless clinically indicated. The study was conducted using a standardized protocol across both institutions. Each participating hospital had a designated principal investigator responsible for protocol adherence and data quality assurance.
2.2. Data source and collection
We collected information on the following variables: age, sex, lesion location and depth, presence of inflammation, bacterial culture results, antibiotic use, and postoperative complications. Cyst size was determined by measuring the longest diameter using ultrasonography. Complications were defined as any condition requiring postoperative antibiotic treatment or reoperation.
2.3. Study population
Only patients with histopathologically confirmed epidermal cysts were included in the study. Patients without culture results or final diagnoses other than epidermal cysts were excluded. Lesions were categorized as inflamed or non-inflamed based on clinical assessment by the operating surgeon and/or ultrasonographic evidence of inflammation.
2.4. Exposure and outcome definitions
The outcomes of this study were to evaluate the microbiological profiles of epidermal cysts, including antibiotic-resistant organisms; differences in bacterial culture results between inflamed and non-inflamed cysts; and postoperative complication rates between the 2 groups.
2.5. Surgical procedure
Preoperatively, all patients underwent ultrasonographic evaluation by the operating surgeon to determine lesion size, depth, shape, and rupture status. Excision was performed through a minimal skin incision that included the central punctum. At Hwahong Hospital, a 3-mm punch tool was used for lesions smaller than 1 cm (Fig. 1A and B), whereas for larger cysts, an elliptical incision of approximately 50% of the maximal cyst diameter was made. In contrast, at Kangnam Sacred Heart Hospital, all lesions were excised using an elliptical incision regardless of size.[17]
Figure 1.
Punch-assisted skin opening and capsule dissection technique for epidermal cyst excision. (A) Creation of a minimal circular skin opening around the central punctum using a 3-mm punch instrument. (B) Sharp dissection and removal of the cyst capsule with an 11-blade scalpel after evacuation and irrigation of the cyst contents.
After expressing and irrigating the cyst contents, the capsule was completely excised. Curettage was performed if necrotic debris was present. Drains were selectively placed in inflamed cases, and all wounds were closed. Drain and suture removal were scheduled individually based on the progress of wound healing. Bacterial cultures were performed intraoperatively.
No routine prophylactic antibiotics were administered. Antibiotics were reserved for patients with clinical deterioration, such as aggravated local inflammation or systemic symptoms (e.g., fever).
2.6. Confounders/variables
Variables collected in this study included age, sex, lesion size, location, depth, inflammation status, bacterial culture results (including organism identification and antibiotic susceptibility), and antibiotic use. Postoperative complication rates were compared between inflamed and non-inflamed groups, with multivariate logistic regression used to adjust for potential confounders, including lesion size, location, depth, and inflammation status.
2.7. Ethical considerations
This study was approved by the Institutional Review Boards of both participating hospitals: Kangnam Sacred Heart (IRB No. 2024-10-005) and Hwahong Hospitals (IRB No. WHH-2025-6). The requirement for individual patient informed consent was waived owing to the retrospective nature of the study. All procedures were conducted in accordance with the Declaration of Helsinki.
2.8. Statistical analysis and sample size justification
Patients with missing bacterial culture results were excluded from the analysis. There was no loss to follow-up, as postoperative outcomes were assessed during routine postoperative visits within the early postoperative period. Categorical variables were compared using the chi-squared test or Fisher exact test, as appropriate. Continuous variables were analyzed using the Student t test. Multivariate logistic regression analysis was performed to identify independent risk factors for postoperative complications. All tests were two-tailed, with a significance threshold of P < .05. Analyses were conducted using Python version 3.13.5 (Python Software Foundation, Wilmington), with the pandas, numpy, and statsmodels open-source packages.
Sample size adequacy was evaluated based on the primary microbiological endpoint, the difference in S aureus isolation rates between inflamed and non-inflamed lesions. Using the observed proportions (24/271 [8.9%] vs 2/173 [1.2%]), approximately 105 lesions per group were required to achieve 80% power at a two-sided α of 0.05. The final cohort (271 inflamed and 173 non-inflamed lesions) exceeded this requirement.
3. Results
3.1. Microbiological findings
Of 474 initially enrolled cases, 30 were excluded owing to non-epidermal cyst pathology (including 11 furuncles, 5 trichilemmal cysts, 2 dermal fibrosarcomas, 4 steatocystomas, 2 pilomatricomas, 1 hidradenoma, 2 neurofibromas, 1 benign spindle cell tumor, 1 organizing hematoma, and 1 fibroepithelial polyp). The final cohort comprised 385 patients with 444 histologically confirmed epidermal cysts (mean age: 46.8 ± 16.4 years).
Bacterial growth was observed in 257 (57.9%) cases. CoNS was isolated in 176 of these (72.1%), 34 (19.6%) of which were MRCoNS. S aureus was detected in 26 patients (5.9%); among them, MRSA was detected in 13 patients. Inducible clindamycin resistance (ICR) was observed in 5 MRSA and 2 MRCoNS isolates. The microbiological data are summarized in Table 1, and the distribution of the most common organisms is illustrated in Figure 2.
Table 1.
Microbial isolates from epidermal cysts (n = 257).
| N (%) | Antibiotic-resistant, N (%) | |
|---|---|---|
| Gram-positive cocci | ||
| Staphylococcus species | ||
| Staphylococcus aureus | 26 (10.1) | MRSA, 13 (50) |
| Coagulase-negative Staphylococci species | ||
| Staphylococcus epidermidis | 85 (33.1) | MRCoNS, 34 (19.6) |
| Staphylococcus lugdunensis | 65 (25.3) | |
| Staphylococcus capitis | 13 (5.1) | ICR, 16 |
| Staphylococcus simulans | 4 (1.6) | MRSA + ICR, 5 |
| Staphylococcus hominis | 3 (1.2) | MRCoNS + ICR, 2 |
| Staphylococcus haemolyticus | 2 (0.8) | |
| Staphylococcus warneri | 2 (0.8) | |
| Staphylococcus caprae | 2 (0.8) | |
| Streptococcus species | ||
| Streptococcus agalactiae | 1 (0.4) | |
| Streptococcus anginosus | 1 (0.4) | |
| Enterococcus species | ||
| Enterococcus avium | 1 (0.4) | |
| Anaerobes | ||
| Finegoldia magna | 3 (1.2) | |
| Gram-positive rods | ||
| Corynebacterium species | ||
| Corynebacterium amycolatum | 4 (1.6) | |
| Corynebacterium glucuronolyticum | 2 (0.8) | |
| Corynebacterium minutissimum | 1 (0.4) | |
| Dermabacter hominis | 5 (1.9) | |
| Bacillus cereus | 1 (0.4) | |
| Actinomyces neuii | 15 (5.8) | |
| Winkia neuii | 1 (0.4) | |
| Cutibacterium acnes | 2 (0.8) | |
| Gram-negative rods | ||
| Enterobacteriaceae | ||
| Escherichia coli | 4 (1.6) | |
| Klebsiella pneumoniae | 1 (0.4) | |
| Klebsiella aerogenes | 1 (0.4) | |
| Enterobacter aerogenes | 1 (0.4) | |
| Morganella morganii | 2 (0.8) | |
| Proteus mirabilis | 1 (0.4) | |
| Providencia rettgeri | 1 (0.4) | |
| Serratia marcescens | 1 (0.4) | |
| Non-fermenting gram-negative rods | ||
| Pseudomonas aeruginosa | 1 (0.4) | |
| Serratia marcescens | 2 (0.8) | |
| Achromobacter xylosoxidans | 1 (0.4) | |
| Malikia spinosa | 1 (0.4) | |
ICR = inducible clindamycin resistance, MRCoNS = methicillin-resistant coagulase-negative Staphylococci, MRSA = methicillin-resistant Staphylococcus aureus.
Figure 2.
Top microbial isolates from epidermal cysts.
3.2. Inflammatory status and clinical characteristics
Of the 444 epidermal cysts, 271 (61.0%) were classified as inflamed. The mean cyst size was larger in the inflamed cyst group than in the non-inflamed cyst group (1.8 ± 1.0 vs 1.3 ± 0.9 cm, P < .001). There were no significant sex-related differences in inflammation rates. Inflamed cysts were significantly more common on the trunk, whereas non-inflamed cysts were more prevalent on the head and neck (P < .001).
Positive bacterial cultures were significantly more frequent in inflamed cysts (64.2%) than in non-inflamed cysts (48.0%; P = .001; Table 2). S aureus was significantly more prevalent in inflamed cysts (13.8%) than in non-inflamed cysts (2.4%), and MRSA was exclusively detected in inflamed cysts. CoNS was more common in non-inflamed cysts than in inflamed cysts (P = .022; Table 3).
Table 2.
Clinical and microbiological features of epidermal cysts.
| Non-inflamed n (%) | Inflamed n (%) | P value | |
|---|---|---|---|
| Number of patients | 140 | 245 | |
| Number of lesions | 173 (39.0) | 271 (61.0) | |
| Age (yr) | 49.3 ± 15.4 | 45.5 ± 16.8 | .033 |
| Sex | |||
| Male | 99 (70.7) | 146 (59.6) | .002 |
| Female | 41 (29.3) | 99 (40.4) | |
| Side | |||
| Right | 78 (45.1) | 121 (44.6) | .796 |
| Mid | 6 (3.5) | 13 (43.8) | |
| Left | 89 (51.4) | 137 (50.6) | |
| Location | |||
| Head and neck | 68 (39.3) | 58 (21.4) | <.001 |
| Trunk | 79 (45.7) | 156 (57.6) | |
| Buttock and genitalia | 17 (9.8) | 38 (14.0) | |
| Extremity | 9 (5.2) | 19 (7.0) | |
| Size (cm) | 1.3 ± 0.9 | 1.8 ± 1.0 | <.001 |
| Depth | |||
| Superficial | 121 (69.9) | 155 (57.2) | <.001 |
| Deep | 52 (30.1) | 116 (42.8) | |
| Bacteria | |||
| Yes | 83 (48.0) | 174 (64.2) | .001 |
| No | 90 (52.0) | 97 (35.8) | |
| Reoperation | |||
| Yes | 2 (1.2) | 8 (3.0) | .360 |
| No | 171 (98.8) | 263 (97.0) | |
| Antibiotic use | |||
| Yes | 0 | 1 | 1.000 |
| No | 173 | 270 | |
Table 3.
Differential bacterial profiles of inflamed and non-inflamed epidermal cysts.
| Non-inflamed (n = 83) | Inflamed (n = 174) | P value | |
|---|---|---|---|
| Gram-positive cocci | |||
| Staphylococcus aureus | 2 (2.4) | 24 (13.8) | .022 |
| Coagulase-negative Staphylococci | 63 (76.0) | 113 (64.9) | |
| Streptococcus species | 0 | 2 (1.1) | |
| Enterococcus species | 0 | 1 (0.6) | |
| Anaerobes | 3 (3.6) | 0 | |
| Gram-positive rods | |||
| Corynebacterium species | 5 (6.0) | 1 (0.6) | .119 |
| Others | 7 (8.4) | 17 (9.8) | |
| Gram-negative rods | |||
| Enterobacteriaceae | 3 (3.6) | 11 (6.3) | 1.000 |
| Non-fermenting | 0 | 5 (12.9) | |
| Antibiotic-resistant Staphylococcus | |||
| MRSA | 0 | 13 | .032 |
| MRCoNS | 14 | 17 | |
| ICR | 3 | 6 | |
| MRCoNS + ICR | 1 | 1 | |
ICR = inducible clindamycin resistance, MRCoNS = methicillin-resistant coagulase-negative Staphylococci, MRSA = methicillin-resistant Staphylococcus aureus.
Reoperation due to postoperative complications was required in 2 non-inflamed cases (1.2%) and 8 inflamed cases (3.0%), with no significant difference between the groups (P = .360). Postoperative antibiotics were administered in only 1 inflamed case: a 55-year-old woman on immunosuppressive therapy for rheumatoid arthritis developed cellulitis with fever, requiring reoperation and intravenous vancomycin for MRSA with ICR.
Multivariate logistic regression analysis revealed no significant associations between postoperative complications and lesion size, inflammation status, depth, location, or bacterial culture results (Table 4).
Table 4.
Logistic regression analysis for reoperation due to postoperative complications.
| Univariate | Multivariate | |||
|---|---|---|---|---|
| OR | P value | OR | P value | |
| Size | 0.445 (0.159–1.250) | .445 | 0.314 (0.090–1.100) | .070 |
| Inflamed | ||||
| No | 1 | 1 | ||
| Yes | 2.455 (0.515–11.716) | .260 | 2.777 (0.531–14.536) | .226 |
| Bacteria | ||||
| No | 1 | 1 | ||
| Yes | 1.123 (0.312–4.043) | .859 | 0.910 (0.241–3.438) | .889 |
| Site | ||||
| Head and neck | 1 | 1 | ||
| Trunk | – | – | ||
| Genitalia | 0.991 (0.110–8.917) | .993 | 1.222 (0.127–11.738) | .862 |
| Extremity | 0.344 (0.037–3.221) | .350 | 0.359 (0.037–3.503) | .378 |
| Depth | ||||
| Superficial | 1 | 1 | ||
| Deep | 1.898 (0.540–6.669) | .318 | 1.605 (0.440–5.854) | .474 |
OR = odds ratio.
4. Discussion
Traditionally, inflamed epidermal cysts have been treated using a 2-stage approach involving initial conservative management followed by delayed excision. However, recent pathophysiological insights have challenged the assumption that inflammation in these cysts reflects an active infection. Many cases are thought to represent a sterile foreign body-type immune response triggered by the rupture of cyst walls and the subsequent release of keratinous material into the dermis.[1,18] Histopathological findings frequently reveal granulomatous inflammation and multinucleated giant cells with minimal evidence of viable microorganisms, supporting the concept of noninfectious inflammation.[19,20] These observations challenge the necessity of routine antibiotic therapy and delayed surgical intervention in all cases of inflammation.
In this study, we performed immediate excision and primary closure in all patients regardless of their inflammatory status, without routine antibiotic use. Among 444 histologically confirmed epidermal cysts, 271 (61.0%) were clinically classified as inflamed. While the inflamed cyst group showed a higher rate of positive bacterial cultures than the non-inflamed cyst group (64.2% vs 48.0%), most isolated organisms were skin commensals, such as CoNS, which is consistent with previous reports.[3,7,8] Notably, S aureus was detected in 26 cases (24 cases of inflamed cysts); over half of these isolates (54.2%) from inflamed cysts were MRSA. In contrast, S aureus isolated from non-inflamed cysts was entirely methicillin-sensitive. These findings suggest that although most inflamed cysts are likely driven by sterile inflammation, a subset may involve actual bacterial infections, particularly with resistant organisms.
Despite the presence of MRSA in some cases, the overall complication rate remained low (2.3%), with no significant differences between the inflamed and non-inflamed cyst groups. Only 1 immunocompromised patient harboring MRSA with ICR required intravenous antibiotics and wound reexploration. This finding highlights the importance of individualized clinical judgment in managing high-risk cases and supports the overall safety of a simplified surgical approach. Evidence from reconstructive and wound surgery literature suggests that meticulous surgical technique and appropriate patient selection may be more critical determinants of wound outcomes than routine antibiotic use, even in complex or potentially contaminated fields, although alternative or adjunctive treatments may be required in selected cases.[21,22]
Our study has several notable strengths. Unlike most previous studies, which have addressed this topic theoretically or with small cohorts, we present real-world evidence from a large cohort of patients, all of whom were histologically diagnosed and had bacterial culture results. Clinical data were prospectively collected using a uniform surgical protocol to enhance the consistency and reliability of the findings. The inclusion of antibiotic susceptibility profiles, including the presence of resistant strains such as MRSA with ICR, also provides microbiological insights that have been underrepresented in the literature.
However, this study has certain limitations. First, the research was not registered prior to data collection, which limits the ability to classify it as a fully prospective study. Second, although a standardized surgical protocol was applied, there were minor differences in excision techniques between the participating hospitals, which may have introduced procedural variability. Given the low incidence of postoperative complications, this study was not powered to detect small differences in complication rates.
5. Conclusion
Immediate excision with primary closure can be safely performed for both inflamed and non-inflamed epidermal cysts without the routine use of antibiotics. These findings support a shift from the conventional 2-stage strategy and suggest that most inflamed cysts do not require preoperative antibiotics or delayed surgery. Nevertheless, the potential for resistant pathogens in selected patients, particularly immunocompromised individuals, warrants continued clinical vigilance. Further prospective studies are required to define the optimal criteria for patient selection and perioperative management.
Author contributions
Conceptualization: Hongki Gwak.
Data curation: Hongki Gwak, Seong Hwan Kim.
Formal analysis: Hongki Gwak.
Methodology: Hongki Gwak, Seung Taek Lim.
Investigation: Seung Taek Lim.
Software: Seung Taek Lim.
Supervision: Seong Hwan Kim.
Validation: Hongki Gwak.
Visualization: Hongki Gwak.
Writing – original draft: Hongki Gwak.
Writing – review & editing: Hongki Gwak, Seong Hwan Kim.
Abbreviations:
- CoNS
- coagulase-negative Staphylococci
- ICR
- inducible clindamycin resistance
- MRCoNS
- methicillin-resistant coagulase-negative Staphylococci
- MRSA
- methicillin-resistant Staphylococcus aureus
The authors have no conflicts of interest to disclose.
This research was supported by a research grant from Jeju National University Hospital in 2025.
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Gwak H, Lim ST, Kim SH. Microbiological and clinical outcomes of single-stage minimal excision of inflamed epidermal cysts without routine antibiotic treatments: A dual-center retrospective cohort study. Medicine 2026;105:19(e48589).
Contributor Information
Hongki Gwak, Email: hkgwak@gmail.com.
Seung Taek Lim, Email: in-somnia@hanmail.net.
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