What is the management for a discharging pilonidal sinus?

Management of a Discharging Pilonidal Sinus

For a discharging pilonidal sinus, the optimal management is surgical excision with off-midline closure when primary closure is desired, or open healing by secondary intention when the wound is complex or infected.

Initial Assessment and Management

When evaluating a discharging pilonidal sinus, consider:

• Presence of active infection or abscess formation
• Size and complexity of the sinus tract(s)
• Previous treatments and recurrences
• Patient factors (obesity, hirsutism, occupation requiring prolonged sitting)

Acute Management of Infected Pilonidal Sinus

If the pilonidal sinus presents with acute infection or abscess:

1. Incision and drainage is the first step for an acute abscess
2. Antibiotics are indicated only if there is surrounding cellulitis or systemic signs of infection
   • For cellulitis with systemic signs, use antibiotics active against streptococci and consider MRSA coverage if risk factors are present 1
   • Typical duration of antibiotic therapy is 5-7 days 1

Definitive Surgical Management Options

1. Surgical Excision with Open Healing (Secondary Intention)

This approach involves:

• Complete excision of all sinus tracts
• Leaving the wound open to heal by granulation
• Regular dressing changes

Benefits:

• Lower recurrence rates (58% lower risk compared to primary midline closure) 2
• Better for infected or complex sinuses

Drawbacks:

• Longer healing time (median 8-10 weeks) 3
• More frequent dressing changes
• Delayed return to work

2. Surgical Excision with Primary Closure

Two main approaches:

a) Off-Midline Closure (Preferred)

• Techniques include Karydakis flap, Limberg flap, or other asymmetric closures
• Significantly better outcomes than midline closure with:
  • Lower infection rates
  • Lower recurrence rates
  • Fewer complications 2

b) Midline Closure (Not Recommended)

• Direct closure of the wound in the midline
• Higher rates of infection (4.7 times higher)
• Higher rates of recurrence (nearly 5 times higher) compared to off-midline closure 2

Advanced Wound Management Options

For complex or recurrent cases, consider:

1. Negative Pressure Wound Therapy (NPWT)

   • May accelerate healing in wounds healing by secondary intention
   • Median healing time of 8 weeks compared to 10 weeks with conventional dressings 3
   • Lower recurrence rates (3.1% vs 12.5% with conventional dressings) 3
   • Particularly useful for large defects after radical excision 4

2. Specialized Dressings

   • Alginate dressings for moderately exudative wounds
   • Foam dressings for highly exudative wounds

Post-Surgical Care and Prevention of Recurrence

1. Wound Care

   • Regular cleansing of the wound
   • Appropriate dressing changes based on wound characteristics
   • Monitor for signs of infection

2. Hair Removal

   • Regular hair removal in the natal cleft area (shaving, laser hair removal)
   • Reduces risk of recurrence

3. Hygiene Measures

   • Maintain good perineal hygiene
   • Avoid prolonged sitting when possible

4. Follow-up

   • Regular follow-up until complete healing
   • Monitor for early signs of recurrence

Decision Algorithm

1. For acute abscess: Incision and drainage first
2. For chronic discharging sinus:
   • If small, localized, non-infected: Consider excision with off-midline closure
   • If complex, extensive, or infected: Excision with open healing (consider NPWT for large defects)
   • If recurrent after previous surgery: Consider more extensive excision with flap reconstruction

Conclusion

The evidence strongly supports surgical management of pilonidal sinus disease. While both open healing and primary closure approaches are used, off-midline closure techniques show clear benefits over midline closure when primary closure is chosen 2. For complex cases, open healing with advanced wound care modalities like NPWT may provide optimal outcomes with lower recurrence rates 3, 4.