Never Pop Those Little Black Spots! Here’s What They Really Are.

Believe for everyone, blackheads are already a very familiar thing, but what if “blackheads” grow in other places besides the nose, such as on the ears? Many people may wonder:

For example, some people post online expressing their confusion

This “huge blackhead” may not look significant, butnever, ever squeeze it!Especially when there is no infection, violent squeezing maytrigger a severe inflammatory response, worsen the infection, and increase the difficulty and scarring of future surgery. At the same time, because the cyst wall still exists, it will recur repeatedly!(Of course, realblackheads should not be squeezed either!)

What are these “blackheads”?

In fact, this “blackhead” that grows elsewhere is called anepidermal cyst(also known as a sebaceous cyst), which is a benign encapsulated subepidermal nodule containing keratin material.

Althoughmost commonly found on the face, neck, and trunk, epidermal cystscan occur anywhere, including the scrotum, genitals, fingers, and oral mucosal cases.

Cysts may progress slowly and persist for many years. The term “sebaceous cyst” is commonly used but actually misnamed, as it does not involve sebaceous glands. Epidermal cysts occur in the infundibulum of the hair follicle. Other common synonyms include infundibular cyst, epidermal cyst, and epidermal inclusion cyst.Although these cysts are confirmed to be benign lesions, rare malignant changes are also possible.

Why do these “cysts” form?

As we all know, our skin naturally secretes oils and continuously sheds old keratin. Under normal circumstances, these substances are expelled through the pores to the surface of the skin. However, sometimes, due to certain reasons(such as duct blockage), this “exit” is blocked,the oils and keratin debris produced by the skin cannot be expelled and gradually accumulate at the site, forming a soft, sometimes visible mass
—that is what we commonly refer to as a “cyst”.

Although it is often called a “sebaceous cyst,” this name is not entirely accurate because the contents of the cyst are mainly not sebum but keratin. However, because this term has been widely used, for the sake of understanding, it will still be used in the following text.

So, why does blockage occur? The main reason isthe duct of the pilosebaceous unit is not patent. It may be related to trauma, acne, hormonal changes, or genetics, but many times, there is no particularly clear cause.

Most cases of epidermal cysts are sporadic. Although they can be seen in autosomal dominant (AD)inherited Gardner syndrome(Gardner syndrome)also known as familial polyposis coli(Figure 3)and Gorlin syndrome also known as nevoid basal cell carcinoma syndrome
(NBCCS)(Figure 4).If multiple cysts appear in unusual locations before puberty, one should be alert to the possibility of a syndrome. In elderly patients with Favne-Racouchot syndrome(Favne-Racouchot syndrome)(cyst and acne due to chronic sun damage)(Figure 5), epidermal cysts may be caused by chronic sun damage.

How to diagnose and differentiate?

Doctors usually diagnose through visual and palpation examinations. Typical sebaceous cysts have the following characteristics:

👉 Appearance:
Round or hemispherical protrusions, varying in size, ranging from the size of a bean to an egg.

👉 Tactile sensation:
Usually elastic, soft in texture, and slightly movable. If the contents are abundant and hard, it may also feel firm.

👉 Characteristic signs:
The cystoften has a dark spot in the center, which is the blocked duct opening and an important clue for diagnosis.

👉 Contents:
If squeezed, a white, tofu-like or grayish-white, malodorous paste may be extruded. This is a mixture of keratin and lipids, and the special odor comes from the decomposition products of these substances.

What issues need to be differentiated from?

Some diseases may have certain similarities and need to be differentiated, such as:

👉 Lipoma:
Deeper and softer, sometimes with unclear boundaries, like a mass of cotton, without a central dark spot.

👉 Abscess/Furuncle:
Painful red swelling caused by acute bacterial infection, usually without a long-standing cyst base, and the pus is yellow rather than tofu-like.

👉 Lymph node enlargement:
Usually located in lymphatic areas such as the jaw and neck, and are tender when infected.

👉 Rare tumors:
For any atypical, rapidly growing, fixed to the skin, and non-healing masses, doctors need to carefully rule out the possibility of malignancy.

Where are they prone to occur?

Epidermoid cysts can occur anywhere on the body where there are hair follicles, but they do indeed have a “preference” for certain areas:

✅ Face, neck, chest, and back:These are areas where sebaceous glands are densely distributed,with vigorous oil secretion, making duct blockage more likely.

✅ Around the ears, earlobes, and behind the ears:This is anextremely commonlocation. The skin around the ears is rich in sebaceous glands, especially the earlobes.Minor injuries from ear piercing, acne, or daily oil secretioncan all lead to duct blockage and cyst formation.

✅ Scalp, groin, and axilla:These areasexperience more frictionandhave dense hair, making them more prone to occurrence.

How to handle them scientifically?

Treatment options depend on the condition of the cyst, such aswhether it is infected or bothersome to the patient.

If the cyst is small and asymptomatic, and does not affect life or the patient does not mind the cosmetic impact, it can be observed, paying attention to changes in thecolor, size, and textureof the cyst, without rushing to treat it.

However, it is important to note thatdo not squeeze!!!Especially when there is no infection, violent squeezing can cause the cyst wall to rupture under the skin,triggering a severe inflammatory response, worsening the infection, and increasing the difficulty and scarring of future surgery.

However, when the cyst shows signs of infection, medical treatment is required.

Pharmacological treatment:Oral antibiotics(such as cephalosporins, clindamycin, etc.)are used to control systemic infections, ortopical antibiotics(such as mupirocin, etc.)help control local bacteria. Sometimes doctors will also injectcorticosteroids(e.g., triamcinolone)into the cyst to reduce inflammation and swelling. However, drug treatment only controls acute infections because the cyst wall still exists,infections can still recur.

Incision and drainage:If an abscess has formed, incision and drainage are needed — that is,making a small incision to drain the pus and cyst contents, relieving pain and pressure. Similarly, this is not a cure, and many people’s wounds heal after drainage, but because the cyst wall is still there,the cyst will recur in the future.

Definitive treatment timing:After the infection has completely subsided(usually 1-3 months), arrange fora planned surgery to completely remove the cyst and its wall.

The core of the surgery is not simply to squeeze out the contents, butthe entire cyst wall must be completely removed. If the cyst wall is left behind, it will grow back quickly, just like “weeds with roots left behind”.

However, it is reassuring that this surgery is minor and can be completed on an outpatient basis with local anesthesia, typically15-30 minutes. The doctor will make a small incision, separate the cyst from the surrounding tissue, and remove it intact, then suture.Complete removal to treat uninfected cysts is the most effective method.

So, in summary, if you have any doubts about the lumps on your body, the wisest course of action is to consult a doctor(dermatology or general surgery).Professional diagnosis is the first step to obtaining the correct treatment.