What a (mostly metaphorical) pain.  For about a dozen years i've had a
little lump on one shoulder from a (presumed acne-related & infected
sebaceous) cyst that i had lanced, drained, & took antibiotics for back
in college.  It's been growing again in the past couple weeks, and now
it's getting fairly tender.  Prospects for the "wait and it'll probably
go away" strategy seem doubtful.  My dim recollection is that the lance
& drain job was done by a dermatologist, certainly the pain killer was
gritting my teeth.  The Mayo Clinic book off my shelf suggests that the
current standard is outpatient surgery with a "local". 

Unlike the good old "everything but pills are free at the Student Clinic"
college days, i'm now on an econo-PPO program.  Through a mixture of
moving around, not getting seriously ill, and not finding one i liked,
i've got no regular doctor to ask about this.  Wasting $100 in co-pay
and an increasingly-painful week getting referred from doctor to general
surgeon to dermatologist to outpatient clinic does not appeal.  Depending
on how one reads my policy's "Pre-existing condition" language, this may
not be covered anyway.

What to do?  Try to get antibiotics from a doctor and cure it painlessly
popping pills?  Randomly select a dermatologist from the plan's list and
try to get some advice on strategy over the phone?  Start looking for a
decent "cash & carry pricing" doctor?  Even if PPO-paid, painless-at-first
outpatient surgery seems far less appealing than "grit teeth, get stabbed". 
Any strategy but "wait & hope longer" also requires a (PPO-member?) MD.... 

18 responses total.

Update!

The seeming infection got worse last night & today.  Bit of fever a few
times this afternoon; noted more-widespread pain & tenderness more often.
A few calls to the phone numbers (four different!) on the back of my
insurance card weren't reassuring - their PPoM network has *NO* "urgent
care" walk-in locations in Washtenaw County; virtually all the network
dermatologists are University of Michigan people (only reachable through
a hostile phone system that i didn't work at penetrating); assuring me
that they would actually cover it would require a two-week wait after
they got a doctor's report on the condition.  I decided to go to St.
Joe Hospital's "Urgent Care" this evening.  (Rumors that have reached 
my ears make St. Joe out to be lots better than the U and my sister 
works there - not completely the cool & rational decision.) 

Walked in the "Urgent Care" door (no appointment) about 7:20.  Couple
minutes to find that check-in was with the ER nurse (being after 5PM).
Maybe a 10 minute wait, then a quick check-in - just a few questions
that struck me as obviously meaningful.  Off to an empty semi-private
exam room with extra stuff (supplies for casts, etc.).  Take my driver's
license for a few minutes, give me a St. Joe ID card & papery plastic
ID bracelet.  A staff doctor appeared about 7:50, a minute of listening
to history & symptoms and he echoed the Mayo Clinic book's diagnosis.
He noted that the on-its-second-infection cyst could be removed in out-
patient surgery, but not 'till after the infection was gone - it was 
lance & drain time.  Nurse & supplies appeared at his summons, there
was a humorous minute's pause while he read how to get an unfamiliar
brand of knife out of its sterile package, then a little painkiller
shot, lance, skwish out some gunk, mop up, push hard to skwish out more,
mop, put in a wick to help it drain, then leave.  Another nurse had 
appeared to dress it, give me a dipth/tetanus shot ("the arm will be
sore tomorrow - which arm do you want this in?"), tell me a bit about 
dressing it myself & what symptoms mean trouble, get my signature on a 
"I know I've gotten some treatment but I ain't cured yet" release form, 
give me a prescription for antibiotics, and see me off with the leftovers
from the dressing stuff they'd opened for me.   

Ignoring the 15 minutes i waited in their pharmacy for the $16 bottle of
pills, i was done & out in an hour.  Never felt rushed, but they *moved*.
I got the impression of extremely competent VIP treatment....which i hope
will not describe the bill.  I didn't sign anything but the release, give 
them any card but the driver's license, nor pay before leaving - they 
assured me that Billing would get to it & mail me the damage report.  
($72 basic overhead "room" rate, plus {unknown}.) 

About 48 hours after treatment, and I'm definitely in the feeling-pretty-
good-but hassled stage of recovery.  The wound is still leaking a bit 
around/through the fat scab (w/wick sticking through).  Pulling adhesive
bandages off my hairy hide to change 'em four+ times per day hurts much
more than anything the doctor did!  Can't get it wet at all, so taking
a shower is a pain.  Hopefully the scab & wick will drop off fairly soon
and tending it get easier.  (I don't recall that they described that part
much...)  

I had a pilonidal cyst removed a few times, and the wick change was 
absolutely unbearable.

Is the whole thing still as sore and tender as before?

My uncle had a cyst behind his ear that my mother (a nurse) use to lance on
a pretty regular basis for him....I know that he did finally get the surgery
to get rid of it though...and I'm sure that it didn't cost that much since
I know that he didn't have insurance at the time.

The very swollen/infected/spreading-sort-of-feelings all vanished quickly
with the lance & skwish.  It's still (at lance + 91 hours) about as sore 
and tender as it was a few hours after lancing.  It's also still running
a bit of dilute blood and aches at times.  Progress since the first night
seems to consist of the wound & big initial scab shrinking while the wick
gets pushed out...all slowly.  (From what they told me at St. Joe & my 
dim memories of the last time, this is par for the course.)  The hair
around it has 'most all gotten pulled out, so changing bandages now hurts
*far* less than it did at first....

About when did your uncle get his cyst removed?  Sounds like it's just
another little-outpatient-surgery these days.....but no idea yet what 
the lance & skwish job cost.  My sister who works there said St. Joe can 
be **really** slow about billing people....used to be that they never
did bill sometimes...<i crosses his fingers>....

He went to a local doc to have it done, I think.  Dr. Reza at Associates in
Internal Medicine is the one that did it I think...and it would have been a
few years ago.  He had good luck because he went in and said "I have no
insurance...do what you can"..and she did. :)  And St. Joe is still really
slow about billing....I've still not recieved bills for the last few blodd
tests that I've had done...after insurance they only ended up being $9 a
piece, but so far I've had four not billed to me to my knowledge.  :)

Hurray!  Got the St. Joe bill yesterday (call it treatment+4 weeks).
Only $123.00!!!  Mailed the check today.  (Yep, i did the "i won't
get a dime from my 'insurance' for this....how much will it cost?"
thing.  I definitely think it helped.)  

St. Joe still has the Assoc. in Internal Medicine group for those who
are insurance-impaired.  The first available appointment was weeks away
when i asked.....

Meanwhile, my lanced cyst is still open and blood/gunk/etc. slowly drool
out with occasional spurts.  Still going through 3-4 SuperSize Band-Aids
as dressings.  Hope it will close up & heal soon....having the cyst itself
removed (minor surgery) is pretty much the alternative.....

(Hmmmm...I'd be a bit concerned if I had a lanced lesion which was still open
and draining 4 weeks after treatment.  Might be worth having it checked out
with a follow-up visit just to be sure nothing unusual is going on.)

The doctors i saw today agreed that nothing unusual was going on, it
wasn't infected, etc.  They also agreed that i'll need surgery to 
get it "fixed" unless something really unusual happens - since the
cyst itself hasn't calmed down in four weeks, it probably isn't gonna.

IBB i got the St. Joe Urgent Care doctor's "personal" bill....and it's
over $230!!!  Looks like i *really* should have done Packard Community
Clinic for initial lance & drain - they've seen me twice now for follow-
ups (same-day appointments!) and they're willing do to the complete
surgery for far less than that.  

PCC's cyst, lump, & bump doctor said i'd get more expert treatment from a 
general surgeon and gave me references to three...he guesses three times 
his price for a surgeon if done in the office, yet more if at a outside 
facility. 

Not sure what i'll do at this point.  The unresolved cyst is far more
annoying than pressing.  PCC and St. Joe seem like known quantities,
one caring and cheap, the other 5-star service at a 5-star price.  In
between (i'd guess) are the surgeons, who are otherwise total unknowns. 
Checking out the insurance angle and asking around seems like a start. 

You might have a cyst that has a "shell" that must be removed to keep it
from coming back.

Getting out every last bit of the cyst "wall" (what they called it) 
was the reason the PCC doctors gave me for preferring a (presumably 
more practiced at the procedure) general surgeon.  With the cyst
inflamed, that wall is bigger, more fragile, and tougher to get out.

This does give me a reason to delay treatment - any amount by which
the inflammation goes down will boost the chances of success of the
operation - no matter who does it.

If the cyst wall is _thicker_ due to inflamation it should be easier to remove
intact, not more difficult.  To reduce the inflammation quickly (shrink it
down) a local steroid might due the trick (injected, not oral).  Seems like
you're gonna get stuck with a big bill no matter what way you go.  I'd think
you'd want to get the best care possible.  After all, it's the only body
you're gonna have for the rest of your life  ;-)

Why not look into Washtenaw county Health Care (I'm assuming you live in
Washtenaw...could be wrong).  they have a way for individuals without
insurance to get care from local docs and clinics.  UoM, St Joes,
Oakwood/Beyer, Packard Community clinic, etc are all sponsors.

I don't know what specifically you need to do to qualify, but you can get more
information by calling them (Washtenaw county Public Health department,
enrollment & Coordination Office) at 734.484-7215.

If you're in Michigan, but not a Washtenaw Cty resident, check out your local
office of michigan rehabilitation services (MRS should be listed in the
phonebook) and see if they can direct you to a similar program.  readers from
other areas/states should look to their public (tax supported) agencies as
well to see what programs or services are available.

Procrastination pays!  :)

Changing the dressing (actually just a Biggie Band-Aid patch) last night,
i noticed that the cyst had shrunk considerably since i last really poked
at it (say, from diameter-of-a-quarter to diameter-of-a-nickel).  Some
very mild prodding painlessly yielded some gunk, so i started poking it
harder.  Took time, but with little pain i got a *lot* of gunk out, and
i couldn't feel anything left of the cyst when i was done.  I'll probably 
have the PCC doctors check it out in a week or so if it stabilizes this
way.  It would be very cool if i got out of needing surgery, but smaller
incision, better odds, and fewer stitches are not to be looked down upon! .

Congratulations!

While you're waiting (assuming there's nothing dangerous going on that you're
avoiding/ignoring) keep the bandage on as firmly as possible, but not so much
as to cut off circulation to your fingers.  A good way to see if it's too
tight is to press on the fingertip, it blanches white as your pressure drives
out the capillary blood, then release the pressure and time how long it takes
to get the color back.  Usually it is within 2-5 seconds, but as long as 8
or 9 seconds is still adequate to avoid danger from too tight a dressing. 
doesn't even matter if your fingers are cold and blue, as long as the
cold/blue color returns within 10 seconds after pressing on it there is
adequate blood flow.

the idea of keeping the bandage on very firmly is to do just what you did by
poking at it.  If there's any sort of opening, and you have pressure on it,
the "gunk" will be forced out onto the bandage and the 'cyst' will continue
to shrink.  Might want to consider using an OTC topical antibiotic on the
cyst, under the bandage, to prevent any infection getting in by the same
route.

Keep up the good work.

Looked up "cyst" and apparently what is being discussed here is a
keratinous cyst (as was stated) also called a wen, sebaceous cyst, or
steatoma. The definition is "A slow growing benign cystic tumor of the
skin containing follicular, keratinous, and sebaceous material and
frequently found on the scalp, easrs, face, back or scrotum". The problem
that a cyst presents is subsequent infection, which makes it an abcess, so
it is an abscess that is being treated so far. 

For larger cysts, removal of the cyst wall is required for a cure, which
seems to be the case here. 

(Source: Merck Manual). 

The three (or 4?) doctors who've looked at my shoulder seemed to agree
that it was a boring-textbook-case of sebaceous cyst.

Being something of a procrastinator and unexcited by the prospect of
surgery, i'm hoping that recent trends will continue - the cyst's size
and activity will continue to fade, the opening in the skin will close
and heal, and i will be able to ignore it again for ~13 years (as i did
when it originally flared up back in college). 

WADR - there are few, if any, sebaceous glands in the skin of your shoulder.
any 1st year medical student should learn that you can't get a sebaceous cyst
where there is no sebaceous gland.  If you look at the definition cited above
of the wen quoted from the Merck Manual you'll see the location is not of the
shoulder.

OTOH - as i said above, if it's improving with current treatment, keep it up.
you may never know the actual pathologic diagnosis (unless excised and
biopsied) but who cares if it goes away?  Waaaayyy back there is early school
I learned that if a treatment or medication was working, _even if it was not
supposed to according to diagnostic tests_, keep up the treatment that was
working rather than switching to the treatment suggested by the testing...this
has always worked for me and my patients.

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