Removal of comedones involves a comedo extractor, an instrument that minimizes skin injury. A round loop extractor is used to apply uniform pressure sufficient to dislodge comedonal contents (Fig. 35.26A,B).

To loosen lesions that offer resistance, insert a pointed instrument such as a lancet or a needle, or a no. 11 blade to carefully incise and expose the contents.

Extraction can be a useful adjunct to topical therapy when blackheads and whiteheads are somewhat resistant to topical retinoids.

Pretreatment with a topical retinoid for 4 to 6 weeks often facilitates the procedure.

A large lesion such as an epidermoid or pilar cyst can be removed through a small hole and heals with excellent aesthetic results.

If the results of this procedure are not completely satisfactory, a standard excision can be performed at a future date.

Superficially administer local anesthesia over the cyst (Fig. 35.27A-D).

Punch the center of the cyst (the “pore”) with a 4-, 6-, or 8-mm disposable punch.

Dissect the cyst wall using forceps, iris scissors, and manual pressure around the cyst. A chalazion curette can be useful to scrape out any residual cyst wall.

Close the defect with a 4-0 nylon stitch.