From the Research
Management of pilonidal sinus disease should prioritize conservative treatment for mild cases, with surgical intervention reserved for chronic or recurrent disease, and off-midline closure being the preferred surgical technique when primary closure is desired. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of conservative management and careful selection of surgical technique to minimize morbidity and recurrence rates 1.
Conservative Management
For mild cases of pilonidal sinus disease, conservative management is recommended. This includes:
- Regular hair removal in the sacrococcygeal area through shaving or laser hair removal
- Meticulous hygiene
- Weight loss if the patient is obese
- Warm sitz baths and drainage for abscesses, as shown to be effective in a study on conservative treatment in children 2
Surgical Management
For chronic or recurrent disease, definitive surgical treatment is recommended. Surgical options include:
- Excision with primary closure
- Excision with secondary healing
- Minimally invasive techniques like pit picking, endoscopic treatment, or flap procedures (Limberg, Karydakis, or V-Y advancement flaps)
- Off-midline closure, which has been shown to have a lower risk of recurrence and complications compared to midline closure 3
Post-Operative Care
Post-operative care is crucial to prevent recurrence and promote healing. This includes:
- Wound care
- Pain management with NSAIDs or acetaminophen
- Continued hair removal to prevent recurrence, as hair penetration into the skin is a key factor in the development of pilonidal sinus disease
Evidence Summary
The evidence supports a conservative approach for mild cases, with surgical intervention reserved for more severe cases. A study from 2018 found that conservative treatment was effective in 79.3% of pediatric patients with pilonidal sinus disease 2. Another study from 2007 found that off-midline closure had a lower risk of recurrence and complications compared to midline closure 3. A more recent review from 2019 emphasizes the importance of careful selection of surgical technique and post-operative care to minimize morbidity and recurrence rates 1.
Key Considerations
When managing pilonidal sinus disease, it is essential to consider the severity of the disease, patient factors, and surgeon expertise. The choice of surgical technique should be tailored to the individual patient, and post-operative care should prioritize wound healing, pain management, and prevention of recurrence. By following this approach, clinicians can provide effective management for patients with pilonidal sinus disease, minimizing morbidity and promoting a rapid return to normal daily activities.