What treatment options are available for a patient with pilonidal cysts in the natal cleft, who has a history of excision of a pyogenic granuloma, and experiences pain, discharge, and occasional bleeding in the area after physical activity, particularly in the context of being a hirsute (having excessive hair) and slightly overweight male?

From the Guidelines

For a patient with pilonidal cysts in the natal cleft experiencing pain, discharge, and bleeding after physical activity, I strongly recommend a comprehensive treatment approach that prioritizes infection control and management of contributing factors, such as excessive hair and weight. Given the patient's history of excision of a pyogenic granuloma and current symptoms, it is essential to consider the potential for recurrent abscesses and the need for early drainage and culture, as suggested by the Infectious Diseases Society of America guidelines 1. The patient's hirsute nature and slightly overweight condition increase the risk of moisture, friction, and bacterial growth in the natal cleft, creating an environment conducive to cyst formation and infection. Some key considerations for treatment include:

• Improved hygiene with regular gentle cleaning of the area using mild soap and water, followed by thorough drying
• Hair removal from the affected area, either by shaving or using depilatory creams every 2-3 weeks
• Weight loss to reduce pressure and friction in the natal cleft
• Warm sitz baths 2-3 times daily for 10-15 minutes to provide relief for acute symptoms
• Topical antibiotics, such as clindamycin 1% or metronidazole 0.75%, to control infection
• Oral antibiotics, like amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days, for more significant infections
• Surgical intervention, including incision and drainage for acute abscesses, or more definitive procedures like excision with primary closure, marsupialization, or flap procedures, for recurrent or severe cases. It is crucial to address the patient's specific needs and contributing factors to prevent further complications and improve quality of life, as emphasized by the guidelines for managing skin and soft tissue infections 1.

From the Research

Treatment Options for Pilonidal Cysts

The patient's condition, characterized by pilonidal cysts in the natal cleft, a history of excision of a pyogenic granuloma, and symptoms of pain, discharge, and occasional bleeding, particularly after physical activity, can be addressed through various surgical treatments. Considering the patient's profile as a hirsute and slightly overweight male, the following options are available:

• Limberg Flap Procedure: This method involves the use of a skin flap to cover the area after excision of the pilonidal cyst, as described in the study by 2. The procedure has shown promising results with low recurrence rates and minimal complications.
• Limited Excision and Open Wound Healing: This approach, discussed in the study by 3, involves the limited excision of the affected area and allowing the wound to heal by open granulation. The method has been associated with lower recurrence rates compared to excision and primary suture.
• Endoscopic Treatment: The study by 4 presents the endoscopic treatment of pilonidal cysts as a feasible and effective option, with good surgical results and low complication rates.
• Incision and Curettage: As mentioned in the study by 5, this method involves the incision of the cyst and curettage of the affected tissue. It is considered a viable option for the treatment of pilonidal cysts, with advantages in terms of morbidity, healing, recurrence, and cure.
• Minimal Surgical Excision under Local Anesthesia: The study by 6 reports on the long-term results of treating pilonidal disease with minimal surgical excision under local anesthesia, followed by healing by secondary intention. This approach has shown to be effective, with low recurrence rates and minimal morbidity.

Considerations for the Patient's Profile

Given the patient's hirsute and slightly overweight profile, it is essential to consider the following factors when selecting a treatment option:

• Hair presence: The presence of excessive hair in the affected area may contribute to the development and recurrence of pilonidal cysts, as discussed in the study by 4.
• Wound healing: The patient's weight and potential comorbidities may impact wound healing, making it crucial to select a treatment option that minimizes the risk of complications and promotes optimal healing, as highlighted in the study by 6.