What is the recommended management for a pilonidal cyst?

Management of Pilonidal Cysts

Incision and drainage is the recommended first-line treatment for inflamed pilonidal cysts, followed by appropriate wound care and preventive measures to reduce recurrence. 1

Initial Evaluation and Diagnosis

• Look for signs of inflammation, abscess formation, or infection in the sacrococcygeal region
• Assess for pain, swelling, purulent drainage, and presence of sinus tracts
• Determine if this is a first occurrence or recurrent condition
• Evaluate for systemic signs of infection (fever, tachycardia, leukocytosis)

Treatment Algorithm

Acute Inflamed/Infected Pilonidal Cyst

1. Incision and drainage is the mainstay of treatment for inflamed pilonidal cysts 1

   • Make adequate incision to allow complete drainage
   • Remove any hair, debris, and necrotic tissue
   • Consider sending tissue for histological examination to rule out rare malignant degeneration (0.1% incidence) 2

2. Antibiotic therapy

   • Not routinely recommended unless there are systemic signs of infection (SIRS) 1
   • If needed, choose antibiotics active against skin flora including MRSA if risk factors present

3. Post-procedure wound care

   • Regular cleaning and packing until healing by secondary intention
   • Follow-up to ensure proper healing

Recurrent or Chronic Pilonidal Disease

For recurrent disease, more definitive treatment may be necessary:

1. Surgical options:

   • Excision with primary closure
   • Excision with open healing (secondary intention)
   • Minimally invasive techniques (incision and curettage) 3

2. Hair removal methods:

   • Laser or intense pulsed light (IPL) treatments have shown promising results with longer disease-free intervals 4
   • Regular shaving of the natal cleft area

Prevention of Recurrence

Recurrence rates for pilonidal disease are high. Preventive measures include:

• Meticulous hair control through regular shaving or laser hair removal of the natal cleft 5
• Improved perineal hygiene with regular cleaning of the area
• Avoidance of prolonged sitting and trauma to the area
• Weight management if obesity is a contributing factor

Conservative Approach

A conservative approach has shown effectiveness in many cases 5:

• Meticulous hair control by natal cleft shaving
• Improved perineal hygiene
• Limited lateral incision and drainage for abscess when needed

Special Considerations

• Surgical incision technique: When surgical intervention is necessary, consider incisions that cross the vertical gluteal fold at an angle to avoid placing the suture line directly in the gluteal fold 6
• Malignancy risk: While rare (0.1%), squamous cell carcinoma can develop in chronic pilonidal disease. Any atypical presentation or non-healing lesion should prompt histological examination 2

Follow-up

• Schedule follow-up visits to monitor healing
• Educate patients about signs of recurrence
• Reinforce preventive measures at each visit

The conservative approach with incision and drainage for acute cases and preventive measures has demonstrated effectiveness with fewer complications and faster return to normal activities compared to extensive surgical procedures 5.