eMedicine Specialties > Dermatology > Benign Neoplasms

Digital Mucous Cyst: Treatment & Medication

Author: Murad Alam, MD, Associate Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery, Department of Dermatology, Northwestern University; Director, Mohs Micrographic Surgery, Northwestern Memorial Hospital
Coauthor(s): David Bickers, MD, Chairman, Carl Truman Nelson Professor, Department of Dermatology, New York Presbyterian Hospital, Columbia University; Natalie Ann Kim,, Northwestern University, The Feinberg School of Medicine
Contributor Information and Disclosures

Updated: Aug 6, 2009

Treatment

Medical Care

Medical care for digital mucous cysts (DMCs) includes the following:

• Soaks
• Local heat
• Massage
• Occlusive treatment with topical steroids and Cordran tape
• Home remedies - Salves, poultices, and plasters
• Application of heparin cream
• Silver nitrate
• Chemical cauterization with phenol
• Digital compression, if the cyst is soft and located over a bony prominence
• Striking with a large book (potential for unintended trauma)
• X-ray therapy and radium irradiation (of historical interest only)

Surgical Care

• The most conservative surgical intervention entails multiple episodes of needling the cyst with a wide-bore needle until resolution is achieved. An appropriately trained patient may continue the repeated drainage and scarification required by this method at home.⁶
• Another technique is cyst aspiration with a large-bore needle, followed by instillation of corticosteroids (triamcinolone, hydrocortisone, betamethasone) with or without lidocaine. Some practitioners prefer to inject proteolytic agents, such as hyaluronidase, in lieu of steroids, but this may be potentially more risky given the communication of the cyst with the joint.⁷
• Cryosurgery has been used to treat digital mucous cysts. Carbon dioxide snow, cryoprobes, and the intermittent spray technique have been used.⁸
• Sclerotherapy was considered a quick and effective method of treatment.⁹ Among the sclerosants infused were Morton fluid, iodine and carbolic acid, sodium morrhuate, ethanolamine, sodium tetradecyl, and polidocanol. Some consider sclerotherapy a dangerous approach because of the potential for extravasation of the chemical into the joint or tendon sheath. However, a 2008 study reported effective treatment of digital mucous cysts with percutaneous sclerotherapy using polidocanol.¹⁰
• Curettage of the cyst may be attempted, and this may or may not be combined with electrodesiccation. Caution should be exercised to reduce the risk of scar.
• High-intensity light sources recently have demonstrated at least short-term success in the management of digital mucous cysts. Cysts have been vaporized with the carbon dioxide laser and treated with infrared contact coagulation.^11,12
• Dermatologic and plastic surgeons have practiced cold-steel surgical excision of digital mucous cysts for several decades. This procedure ranges from simple excision of the cyst to wide, radical excision with possible graft¹³ or flap reconstruction. Flaps used for reconstruction have historically been rotation flaps,¹⁴ but rhomboid flaps¹⁵ have been used safely and reliably and may be easier to apply in selected situations.
• Another approach is marsupialization, or excision of the whole proximal nail fold, with subsequent healing by secondary intention.
• In recent years, excision and debridement of joint osteophytes has been recognized as a necessary adjunct to reduce the risk of recurrence. Some hand surgeons believe that excision and debridement of the marginal osteophyte without removal of the cyst itself may be the best intervention. This results in less postoperative impairment in joint motion and fewer nail deformities since cyst dissection around the germinal matrix potentially may injure the underlying matrix and cause scarring. In general, more aggressive dissection leads to fewer recurrences and more nail deformities.
• More recently, nail surgeons have attempted to treat recurrent or refractory cysts by repairing the causative leak of joint fluid in such lesions.¹⁶ Methylene blue dye is first injected into the distal interphalangeal (DIP) joint. Then, a skin flap is raised around the cyst to find the area of dye-filled communication between the joint space and the cyst. This communication is then sutured shut and the flap is dropped back into place without tissue resection.
• Overall, significant disagreement exists in the literature regarding optimal treatment approaches.
  • Dermatologists tend to favor more conservative treatments such as multiple needling or aspiration followed by steroid injection; they have reported high success rates and relatively low risks of recurrence.
  • Hand surgeons have noted success and rare recurrence with osteophyte excision and debridement, but their patient population is comprised of those who fail other treatments. All of the literature is biased toward the minority of patients who seek medical care for their digital mucous cysts. Asymptomatic cysts and spontaneous regression appear to be common, with several series suggesting that the likelihood of the latter may approximate 50%.
  • Additionally, as the aggressiveness of interventions to treat digital mucous cysts increases, the associated costs also increase. Conservative treatments offer the prospect of low cost, low morbidity, and the elimination of disability and time loss related to recovery from surgery.
  • Consequently, a reasonable treatment plan for symptomatic digital mucous cysts may entail initial needling or aspiration and injection; if these modalities fail repeatedly, patients may be referred to a hand surgeon for more radical surgery but must be forewarned of the increased risk of complications and offered the option of simply deferring treatment for this essentially benign entity.

Consultations

• Dermatologist
• Dermatologic surgeon
• Hand surgeon

Medication

Many medications have been used for the treatment of digital mucous cysts. At present, injectable corticosteroids commonly are used, and the most frequently administered agent is triamcinolone acetonide. If a ruptured or partially treated cyst becomes infected, antibiotic therapy with a penicillin or cephalosporin (eg, cephalexin) may be indicated. Silver nitrate and heparin cream also have been used. Currently, no standard doses exist for heparin or for silver nitrate.

Corticosteroids

May result in involution or shrinkage of the cyst. Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Triamcinolone (Aristocort)

Used in dermatology for its anti-inflammatory and antipruritic properties. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Dilute with isotonic sodium chloride solution to a concentration of 2.5-5 mg/mL prior to injection. Total quantity injected may be 0.10 mL or less and a 30-gauge needle is used.

Anti-infectives

Treat skin and skin structure infections caused by susceptible organisms.

Cephalexin (Keflex, Biocef)

First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.

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