The issue raised by your question is actually two parts: what options are there for treating comedonal cysts; and what can be done to minimize keloidal scarring in high-risk areas, such as the shoulders?

I’ve had success in reducing the size of many sebaceous or comedonal cysts by injecting them with triamcinolone acetonide. My usual concentration is 10 mg/mL, and the cyst may accommodate up to 0.3 mL. I use a tuberculin syringe, and a 30-gauge needle to enter the cavity. Risks include potential atrophy if the injection goes into the fat, rather than the cyst, and potential rupture of the cyst that will lead to a local inflammatory reaction. Multiple injections one month apart may be needed in order to shrink the cyst. Since this avoids cutting the skin, I have avoided keloid activation. In addition, the steroid effect can also improve any pre-existing keloid.

If surgery is the only option, then conservative excision and gentle manipulation of the skin can minimize keloid formation. Close observation for early keloidal activity at 6 to 8 weeks post-op is required. If there’s evidence of keloidal activity, then intralesional steroid injection will curb the formation of the scar.

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