What is the treatment for a pilonidal abscess?

Treatment of Pilonidal Abscess

The definitive treatment for a pilonidal abscess is surgical drainage with identification and removal of the epithelial sinus tract, which can be performed as a single-step procedure to prevent recurrence. 1, 2

Initial Management

Surgical Approach

• Incision and drainage is the cornerstone of treatment for pilonidal abscess
• Complete evacuation of purulent material is essential
• The procedure should include:
  • Access to the abscess cavity
  • Complete evacuation of purulent material
  • Irrigation with sterile saline solution
  • Identification and removal of epithelial sinus tract when possible

Surgical Options

1. Simple drainage

   • Traditional approach but has high recurrence rates (>40%) 3
   • Often requires a second definitive procedure 4-8 weeks later

2. Unroofing and curettage

   • Higher healing rates (96% vs 78.7%) and lower recurrence rates (11% vs 42%) compared to simple drainage 3
   • Recommended as superior to simple drainage

3. Marsupialization

   • Single-step radical treatment with 81.3% success rate
   • Can be performed in outpatient setting under local or spinal anesthesia
   • Healing time: 4-10 weeks in 95.3% of patients 4

4. Excision with primary closure

   • Can be performed during acute phase
   • Allows for earlier return to normal activities (mean 13 days) 5
   • Various closure techniques exist:
     • Direct midline suture for small excisions
     • Asymmetric closure techniques (Karydakis, Bascom) for larger wounds 6

Antibiotic Therapy

While the evidence specifically for pilonidal abscess antibiotics is limited in the provided materials, general principles for complex abscesses apply:

• Antibiotics are indicated if:

  • Systemic signs of infection are present
  • Patient is immunocompromised
  • Source control is incomplete
  • Significant surrounding cellulitis exists 1

• Recommended empiric antibiotic regimens:

  • Coverage should include Gram-positive, Gram-negative, and anaerobic bacteria 1
  • Oral options: Amoxicillin-clavulanic acid 875/125 mg every 12 hours
  • For suspected MRSA: Trimethoprim-sulfamethoxazole or doxycycline
  • For severe infections requiring hospitalization: IV antibiotics may be necessary 7

Post-Procedure Care

• Daily sitting in warm tub baths with gentle cleansing
• Regular wound assessment and dressing changes
• Pain management with acetaminophen or NSAIDs
• Monitor for signs of recurrence or complications
• Return to normal activities typically within 7-10 days for less invasive procedures 3

Considerations and Pitfalls

• Recurrence prevention: Complete removal of the epithelial sinus tract is crucial to prevent recurrence
• Wound healing: Open wounds require longer healing time but have lower recurrence rates compared to primary closure techniques
• Setting: While some procedures can be done in office settings, hospital operating rooms with proper anesthesia may be preferable for more extensive procedures 2
• Follow-up: Regular assessment is essential to monitor healing and detect early recurrence

Patient Selection Factors

• Age and sex: Pilonidal disease occurs twice as often in men as in women, usually between ages 15-30 6
• Extent of disease: More complex cases with multiple sinuses may require more extensive procedures
• Patient preferences: Consider patient's ability to manage wound care and time off work/school when selecting approach