Injecting ideas (and therapies) in digital mucous cysts

By Warren R. Heymann, MD, FAAD
Oct. 8, 2025
Vol. 7, No. 40

I am almost embarrassed to admit it, but I go on clinical autopilot when it comes to digital mucous (myxoid) cysts (DMCs). I offer a brief explanation, reassure the patient that the lesion is benign, refer the patient to a hand surgeon or podiatrist, and move on. Somewhere along the line, I must have stopped treating these lesions, probably due to a lack of success. I must offer an apology to these patients. Quoting Thomas Edison, “You only fail when you stop trying.” By that definition, I am a DMC failure. Maybe it is time to rekindle the therapeutic flame for DMCs before referring the patient to the surgeon.

DMCs are common lesions, usually seen in middle-aged to elderly patients, and three times more likely in women. (1) DMCs are pseudocysts of the fingers or toes, localized between the distal interphalangeal (DIP) joint and proximal nail fold (type A), within the proximal nail fold (type B), or beneath the nail matrix (type C). (2) Lesions appear as translucent tumors that may be accompanied by pain and decreased DIP motion. (3) Nail deformities such as nail grooves are common complications. (1) Irregular grooving of the nail plate that fluctuates with DMC volume results in a “wave” pattern resembling waves reaching the shore. (5) Lesions may ulcerate, drain, and become secondarily infected. (1) Differentiating DMC from Heberden nodes (not cystic), gout (sudden onset of a red, hot swollen [usually great] toe), or giant cell tumor of the tendon sheath (volar, mobile nodule) is straightforward.

DMCs have long been associated with osteoarthritis. Hill et al., in a study of 218 patients (53 with DMC versus 163 controls), demonstrated that DIP joint osteoarthritis severity was statistically significantly greater for patients with DMCs. (2)

Despite being described in 1883 (3), the pathophysiology of DMC remains controversial but is believed to be due to degenerative changes in the fibrous capsule or synovial tissue. (4) According to Meyers and Fallahi, “It has been proposed that mucous cysts could be an outpouching of the synovial lining of a joint. Studies have been performed where dye is injected into the joint and has shown communication between the joint and the cyst. However, when the dye is injected into the cyst, there does not appear to be a communication of the cyst to the joint. This could indicate that there is a one-way valve, where the fluid is originating from the joint but it is unable to go back into the joint. Others have proposed that there could be a rent in the tendon sheath or the capsule surrounding the joint, causing irritation and a local reaction and thus the formation of the cyst. Another theory is that the connective tissue surrounding the joint is undergoing mucoid degeneration, with byproducts of collagen breakdown collecting in the cyst.” (1)

Managing DMCs begins with reassuring patients that these lesions are not dangerous; if the lesion(s) is symptomatic and osteoarthritis is a concern, an X-ray of the digits is in order. Frequently performed techniques include puncture, aspiration, and injection with a steroid or hyaluronidase, sclerotherapy, cryotherapy, infrared coagulation, and laser treatment. Specific injected agents include steroids (triamcinolone), sclerosing agents such as polidocanol, and bleomycin. (6,7) Injections may be aided by visualizing the DCM by transillumination using a dermatoscope. (8) (The image in the article is so impressive, you may want to transilluminate lesions just for fun — even if you are not injecting them!) Surgical procedures include excision of the pseudocyst, osteophyte debridement, and removal/ligation of any connecting stalk. (4,6) Overlying skin resections may be followed by skin grafting or local flap coverage. (4) Of the various therapeutic options, surgery offers the highest cure rate (95%), followed by sclerotherapy (77%), cryotherapy (72%), intralesional steroids (61%), and simple aspiration (39%). (7)

In conclusion, some therapeutic options for DMCs may be effective prior to referring the patient for surgery. To quote Thomas Edison again, “Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time.” Lesson learned. I will try again.

Point to Remember: Digital mucous (myxoid) cysts are often associated with osteoarthritis. Multiple therapeutic maneuvers may be utilized, but the best results remain with surgical excision.

Our expert’s viewpoint

Maressa C. Criscito, MD, FAAD, FACMS
Assistant Professor, Ronald O. Perelman Department of Dermatology
NYU Grossman School of Medicine

Digital mucous cysts, also known as digital myxoid pseudocysts, are common benign lesions located around the nail unit and can be quite the nuisance to patients and physicians alike! While several treatments have been described, there currently lacks consensus as to when and how these lesions should be treated. Treatment is often best guided by patient symptoms and impact on quality of life as well as location and chronicity of the tumor. (9) As mentioned by Dr. Heymann, surgical approaches have the highest cure rate, although potential adverse events, such as nail dystrophy, tendon injury, joint stiffness, amongst others, must be considered. The success of surgical treatment is often attributed to the scarring of the stalk and different approaches may be utilized to achieve this outcome. (10) Dissecting the lesion from its origin, with electrosurgery or suture ligation at its source, is considered the ideal approach. In some lesions, the stalk appears as a narrowing of the pseudocyst at the distal interphalangeal joint (DIPJ), which then can be directly ligated with suture. If there are multiple stalks, or if the stalk is more difficult to visualize, electrosurgery may be utilized as a “field treatment” to scar the stalk in given areas. (9) The use of methylene blue, injected into the joint, has also been described as a way to identify the stalk and ligate accordingly. (11) Even though digital mucous cysts are rarely firm and well-defined, instead often presenting as longstanding and recurrent, surgical dissection with ligation of the stalk should still be considered to allow for definitive treatment of these lesions.

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References

1. Meyers AL, Fallahi AKM. Digital Mucous Cyst. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32644518.

2. Hill RC, Bartolotta RJ, Laur O, Shaikh B, Miller RC, Richert B, Lipner SR. Digital myxoid pseudocysts are associated with osteoarthritis severity in a retrospective cohort study at a single academic institution. J Am Acad Dermatol. 2025 Mar;92(3):592-594. doi: 10.1016/j.jaad.2024.10.047. Epub 2024 Nov 4. PMID: 39505270.

3. Eliassow A, Frank SB. Pathogenesis of synovial lesions of the skin. Arch Dermatol Syphilol 1942;46:691–4.

4. Vanmierlo B, Vandekerckhove B, DE Houwer H, Decramer A, VAN Royen K, Goubau J. Digital mucous cysts of the finger without osteoarthritis: optimizing outcome of long needle trajectory aspiration and injection. Acta Orthop Belg. 2023 Jun;89(2):249-252. doi: 10.52628/89.2.11582. PMID: 37924541.

5. Domínguez-Cherit J, Rosales-Sotomayor Á. The "Waves Sign" in Digital Myxoid Pseudocyst. Skin Appendage Disord. 2024 Jun;10(3):243-245. doi: 10.1159/000536137. Epub 2024 Jan 30. PMID: 38835718; PMCID: PMC11147518.

6. Raman KS, Ahmad D, Mourad N, Biran BS. Injection Therapy for Digital Mucous Cysts. J Cutan Med Surg. 2023 Mar-Apr;27(2):173-174. doi: 10.1177/12034754231152225. Epub 2023 Jan 31. PMID: 36721990.

7. Kim YJ, Lee HM, Cho JH, Kim DH, Ahn HH, Seo SH. Efficacy of Bleomycin Intralesional Injection for Treating Digital Mucous Cysts: A Comparative Study of Corticosteroid Intralesional Injection and Surgical Excision. Ann Dermatol. 2024 Jun;36(3):180-185. doi: 10.5021/ad.23.131. PMID: 38816979; PMCID: PMC11148311.

8. Gupta MK, Lipner SR. Transillumination for improved diagnosis of digital myxoid cysts. Cutis. 2020 Feb;105(2):82. PMID: 32186525.

9. Baltz JO, Telang GH, Robinson-Bostom L, Jellinek NJ. Pseudo-encapsulated digital myxoid cyst: An unusual manifestation of a common disease. Dermatol Surg. 2021 Mar 1;47(3):422-424.

10. Jabbour S, Kechichian E, Haber R, Tomb R, et al. Management of digital mucous cysts: a systematic review and treatment algorithm. Int J Dermatol 2017;56:701-8.

11. De Berker D, Lawrence C. Gangion of the distal interphalangeal joint (myxoid cyst): therapy by identification and repair of the leak of joint fluid. Arch Dermatol 2001;137:607-10.

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