Management of Pilonidal Tract Infection
The definitive management of pilonidal tract infection requires surgical drainage as the cornerstone of treatment, with aspiration being a viable alternative in selected cases, followed by appropriate antibiotic therapy targeting common skin and soft tissue pathogens.
Initial Assessment and Management
Acute Pilonidal Abscess
- Source control is the primary intervention
- Surgical drainage is the gold standard for most patients 1
- Aspiration under local anesthesia can be effective in selected patients (83% success rate) 2
- Not suitable for patients with immunosuppression, diabetes, overlying skin necrosis, or perforation
- Complete evacuation of purulent material is essential
Antibiotic Therapy
First-line oral antibiotic options:
For severe infections requiring hospitalization:
Duration of treatment:
- Typically 5-7 days 3
- Reassess after 48-72 hours for clinical improvement
Definitive Management Options
1. Drainage and Delayed Excision
- Initial drainage of abscess
- Delayed excision (after 3 weeks) with primary closure
- Higher recurrence rate (14% at 12 months) compared to secondary healing 4
2. Excision with Secondary Healing
- Complete excision of the sinus tract
- Wound left open to heal by secondary intention
- Lower recurrence rate but longer healing time 4
- Recommended for grossly infected and complex cysts 5
3. Excision with Primary Closure
- Complete excision followed by immediate closure
- Faster healing time but higher infection rate (14%) 5
- Single-dose antibiotic prophylaxis with cefoxitin does not significantly improve outcomes 6
4. Marsupialization
- Excision of the sinus tract followed by suturing the edges of the wound to the underlying tissue
- Lower recurrence rate (4%) compared to primary closure (11%) and wide excision (13%) 5
Special Considerations
Recurrent Pilonidal Disease
- More aggressive surgical approach may be needed
- Consider marsupialization for recurrent cases due to lower recurrence rates 5
Unusual Locations
- While most common in sacrococcygeal region, pilonidal sinuses can occur in other areas with hair under friction (axillae, groin, anterior chest wall) 7
- Management principles remain the same regardless of location
Follow-up Care
- Regular wound assessment until complete healing
- Good hygiene of the affected area
- Hair removal from the affected area to prevent recurrence
- Patient education about signs of recurrence
Complications to Monitor
- Wound infection
- Delayed healing
- Recurrence (4-14% depending on surgical technique) 5, 4
- Spread to deeper tissues
Prevention of Recurrence
- Regular hygiene of the affected area
- Hair removal methods (shaving, laser hair removal)
- Avoiding prolonged sitting
- Weight management for overweight patients
The management approach should be selected based on the severity of infection, patient factors, and surgical expertise available. While aspiration with antibiotics shows promising results in selected patients, surgical intervention remains the mainstay of treatment for most pilonidal tract infections.