What is the management plan for a pilonidal cyst?

Management of Pilonidal Cyst

Incision and drainage is the recommended primary treatment for pilonidal cysts that are inflamed or infected, followed by appropriate wound care and preventive measures to reduce recurrence. 1

Initial Assessment and Management

Acute Presentation (Inflamed/Infected)

• Incision and drainage is the first-line treatment for inflamed pilonidal cysts/abscesses 1
• After drainage, cultures are not routinely recommended unless:
  • Patient has systemic signs of infection (fever, tachycardia, tachypnea)
  • Patient is immunocompromised
  • Previous treatment failure 1

Antibiotic Considerations

• Antibiotics are generally not needed after successful drainage unless:
  • Presence of SIRS (temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or abnormal WBC)
  • Markedly impaired host defenses 1
• When indicated, antibiotics should cover common skin flora, particularly Staphylococcus aureus

Definitive Surgical Management Options

For recurrent or chronic pilonidal disease, several surgical approaches exist:

1. Excision with primary closure:

   • Fastest healing time
   • 14% postoperative infection rate
   • 11% recurrence rate 2

2. Wide excision without closure (open healing):

   • Longer healing time
   • 13% recurrence rate
   • Should be reserved for grossly infected or complex cysts 2

3. Marsupialization:

   • Moderate healing time
   • Lowest recurrence rate (4%) 2

Conservative Management

Conservative treatment may be considered for children and in cases where surgery is contraindicated:

• Meticulous hair removal
• Improved perianal hygiene
• Warm sitz baths
• Drainage for abscess formation

Studies show complete healing in approximately 79% of pediatric patients with conservative management alone 3

Preventive Measures to Reduce Recurrence

• Hair removal: Regular shaving or laser hair removal of the sacrococcygeal region
  • Laser and intense pulsed light (IPL) treatments have shown promise in preventing recurrence for 7-36 months 4
• Hygiene: Regular cleaning of the sacrococcygeal area
• Avoid prolonged sitting: Especially on hard surfaces
• Weight management: Obesity increases risk of recurrence

Follow-up Recommendations

• For recurrent pilonidal disease, search for local causes such as foreign material or persistent hair 1
• Recurrent abscesses should be drained and cultured early 1
• Consider a 5-10 day course of antibiotics active against cultured pathogens for recurrent cases 1

Important Considerations

• Histological examination: All excised pilonidal cyst tissue should undergo histological examination to rule out rare malignant transformation (0.1% incidence) 5
• Recurrence risk factors: Hirsutism, obesity, poor hygiene, sedentary lifestyle
• Surgical timing: Elective procedures are preferred over emergency surgery when possible to reduce complications

Treatment Algorithm

1. Acute presentation with abscess:

   • Incision and drainage
   • Antibiotics only if systemic signs of infection present
   • Plan for definitive treatment after acute inflammation resolves

2. Chronic or recurrent disease:

   • Consider excision with primary closure or marsupialization for best outcomes
   • Reserve wide excision for complex or grossly infected cases
   • Consider laser/IPL treatment for hirsute patients with recurrent disease

3. Mild or pediatric cases:

   • Trial of conservative management first
   • Proceed to surgical options if conservative measures fail

By following this evidence-based approach, the risk of recurrence can be minimized while optimizing healing time and patient comfort.