The contents of this lesion are so lumpy that you can’t tell for sure if the “core” was removed. However, given the violence of the extraction and the use of a finger (instead of a small haemostat or scissors) to break up the loculations, I am sangine that much of the cyst wall is still inside. We can expect a fourth installment.

Now if the cyst wall had been extracted on each of the pt’s visits, I would be concerned. The exudate sure looks like keratin rather than pus, which makes me concerned. If it were pus, then I would want a chest series, because this kind of chronic lesion would be consistent with a pleural effusion. (The fellow in Africa who had four litres of puss/rasberry pudding out of his back almost certainly was draining a pleural effusion.)

So I am going to hope that this recurrent lesion is due to surgical technique that seeds the whole field with microscopic bits of the involved hair follicle. If it’s not, then I would want to take a few biopsies. Yes, it’s extremely rare for a dermal cyst to go malignant, but it does happen.

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