What are the management options for pilonidal cysts?

Management of Pilonidal Cysts

Surgical excision is the treatment of choice for pilonidal cysts causing discomfort or difficulty walking, showing growth during follow-up, or presenting with suspicious features, with complete surgical excision providing definitive histopathological diagnosis and prevention of future complications. 1

Diagnostic Assessment

• Clinical examination should assess:
  • Size, location, tenderness, and mobility of the cyst
  • Presence of drainage, infection, or sinus tracts
  • Extent of surrounding inflammation

Treatment Options

Conservative Management

• Appropriate for asymptomatic or minimally symptomatic cases:
  • Meticulous hair control by natal cleft shaving 2
  • Improved perineal hygiene 2
  • Regular cleaning of the area

Interventional Options

1. Surgical Excision Techniques:

   • Excision with primary closure: Fastest healing time despite 14% infection rate 3
   • Marsupialization: Lowest recurrence rate (4%) compared to primary closure (11%) and wide excision (13%) 3
   • Wide excision with secondary healing: Reserved for grossly infected and complex cysts 3

2. Minimally Invasive Approaches:

   • Limited lateral incision and drainage: For acute abscess management 2
   • Laser and light treatments: Diode laser or intense pulsed light (IPL) may provide longer disease-free intervals with fewer recurrences 4

Treatment Algorithm

1. For asymptomatic or incidentally discovered cysts:

   • Conservative management with hair removal and hygiene measures
   • Regular follow-up to monitor for changes

2. For symptomatic cysts without active infection:

   • Surgical excision with primary closure or marsupialization
   • Consider laser/IPL treatment for hirsute patients with recurrent disease 4

3. For acutely infected cysts with abscess:

   • Incision and drainage as initial management
   • Definitive surgical excision after resolution of acute infection
   • Consider marsupialization for complex or recurrent cases 3

Considerations for Specific Scenarios

• Recurrent disease: Consider marsupialization or laser/IPL treatment 4, 3
• Extensive disease with multiple sinuses: Wide excision may be necessary despite longer healing time 3
• Patients with significant hirsutism: Adjunctive laser/IPL treatment may reduce recurrence 4

Pitfalls and Caveats

• Simple needle aspiration or incision and drainage alone have high recurrence rates and should be avoided as definitive treatment 1
• Wide excision with secondary healing results in prolonged wound healing and significant morbidity; should be reserved only for extensive or complex cases 3, 5
• Conservative management alone may be insufficient for symptomatic or recurrent disease 5
• Failure to address predisposing factors (excessive hair, poor hygiene) may lead to recurrence regardless of surgical approach 2

Follow-up Recommendations

• Regular follow-up until complete healing
• Education on preventive measures including hair removal and hygiene
• Long-term monitoring for recurrence, especially in patients with risk factors