Here is my case history. For months I had a tiny (pinprick size)scab just above my right ankle. Some time in mid-June, I noticed that the scab had fallen off. The area near the scab showed some redness so I covered it with a small bandage and some neosporin ointment. I didn't think too much of this until some weeks later when I realized that this lesion was not healing and appeared to be forming a large boil. I became concerned and paid a visit to my PCP who diagnosed this as an abscess. She prescribed Zithromax. Shortly after taking the Zithromax a cellulitis broke out covering a 3x4 inch area of my right leg about an inch above the ankle. I returned to my PCP who gave me another free sample of Zithromax because there was still some pussiness in the affected area. Even after 2 courses of Zithromax, I still had a reddish purple lesion just above my right ankle on the outer part of my leg. The irregularly shaped lesion extended up my leg about 7 cm and was about 2.5 cm wide. It appeared to be filled with fluid. I finally asked my PCP for referral to a dermatologist.
On my 1st visit to the derm. he took a brief look at the lesion and prescribed bactroban and clobetasol ointments which I used faithfully for 2 weeks. When I returned to his office, he performed a shave biopsy and a culture because the condition had not improved. He told me that I had 2 cysts and that this was a very unusual area for cysts to form. He incised and drained the cysts. (I believe that the 2 cysts are interconnected because I feel some fiber between them.) When I returned 2 weeks later, he told me that the biopsy only showed some scar tissue and that the culture had not grown anything. The smaller cyst appeared to be healing, but there was still some significant swelling in the larger cyst. The biopsy site was still open and oozing slightly. He gave me 4 cortisone injections into the larger cyst. The cortisone did flatten the larger cyst; however, the smaller cyst suddenly became inflamed and filled with fluid. The biopsy site had still not healed. I visited my derm. 2 weeks later on 9/15 and he incised and drained the cyst and gave me some cortisone injections in areas of the lesion that he had not injected previously. He told me to call him back in 2 weeks and that he would do a deeper punch biopsy if there was still no improvement. There was some initial improvement from the cortisone so I did not call, but now 4 weeks later I still have the lesion; I can feel lumps and fiber under the skin, and there are some small inflamed areas along the lesion which I am afraid will flare up again given my past history.
Here are my questions. Should I continue with my present dermatologist or seek a second opinion? Have I received the proper treatment so far? Why wasn't the punch biopsy done in the first place? I understand that cysts will come back if the cyst wall is not removed. Should I seek treatment from a general or plastic surgeon who could remove the lesion?
I think you've been properly taken care of so far. It isn't usually necessary to do a punch biopsy in the clinical circumstances you describe. That's why your dermatologist waited until clarification seemed worthwhile. I'm obviously not sure what exactly is going on now, but it seems likely that what you're feeling under the skin is just scar tissue. I see no need for you to seek excision now. If the infection flares up again, you can always look at surgery later, since you may very well not need it. If injections of cortisone helped, that's pretty good evidence that the area isn't infected, at least now. I'd wait, and bring any worsening to the doctor's attention.
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