Should a pilonidal abscess be packed after incision and drainage?

Management of Pilonidal Abscess: To Pack or Not to Pack

Based on current evidence, packing is not recommended after incision and drainage of a pilonidal abscess as it increases pain, adds healthcare costs, and does not improve healing outcomes.

Current Evidence on Packing

The 2021 World Society of Emergency Surgery (WSES) guidelines specifically address this issue and state that no recommendation can be made regarding the use of packing after drainage of an anorectal abscess based on the available literature 1. However, they note that:

• Packing is costly and painful
• Studies have not shown that packing adds benefit to the healing process
• A multi-center observational study of 141 patients found no advantage to packing

Recommended Approach to Pilonidal Abscess

Initial Management

1. Incision and drainage is the primary treatment for pilonidal abscess 1
2. Timing of surgery should be based on presence and severity of sepsis 1
3. Incision placement should be kept as close as possible to the anal verge to minimize potential fistula length while providing adequate drainage 1
   • Off-midline incisions heal approximately 3 weeks faster than midline incisions 2

Post-Drainage Management

1. Leave the wound open without packing
2. Daily wound care with warm tub baths or showers
3. Consider antibiotics only if the patient has:
   • Systemic signs of infection (SIRS)
   • Markedly impaired host defenses
   • Significant surrounding cellulitis 1

Potential Complications and Prevention

Risk Factors for Recurrence

• Inadequate drainage
• Loculations
• Horseshoe-type abscess
• Delayed time from disease onset to incision 1

Recurrence Prevention

• Complete and thorough drainage of the abscess cavity
• Consider definitive treatment for recurrent cases:
  • Curettage during initial drainage has shown lower recurrence rates (11%) compared to simple drainage (42%) 3
  • Novel approaches like endoscopic pilonidal abscess treatment (EPAT) show promising results with reduced morbidity and quicker healing 4

Special Considerations

For recurrent pilonidal abscesses:

1. Search for local causes such as foreign material or hidradenitis suppurativa 1
2. Drain and culture early in the course of infection 1
3. Consider definitive treatment options:
   • Elective excision and primary closure after resolution of acute inflammation 5
   • Aspiration with antibiotics may convert emergency cases to elective procedures with better outcomes 5

Conclusion

The evidence does not support routine packing of pilonidal abscesses after incision and drainage. The focus should be on adequate drainage, proper wound care, and consideration of definitive treatment for recurrent cases.