What are the treatment options for pilonidal disease?

Treatment Options for Pilonidal Disease

Incision and drainage is the recommended first-line treatment for inflamed pilonidal disease, while minimally invasive techniques or marsupialization are preferred over radical excision for chronic cases due to faster healing and lower recurrence rates. 1, 2

Acute Pilonidal Disease

Initial Management

• For inflamed or abscessed pilonidal disease:
  • Incision and drainage is the recommended treatment 1
  • Antibiotics are generally not needed unless there are signs of systemic infection (SIRS) such as:
    • Temperature >38°C or <36°C
    • Tachypnea >24 breaths per minute
    • Tachycardia >90 beats per minute
    • White blood cell count >12,000 or <400 cells/µL 1

Post-Drainage Care

• After drainage, implement conservative measures:
  • Meticulous hair control through natal cleft shaving
  • Improved perineal hygiene
  • Regular wound cleaning 3

Chronic Pilonidal Disease

Conservative Management

• Conservative, non-excisional therapy should be attempted first:
  • Regular natal cleft shaving
  • Improved perineal hygiene
  • Limited lateral incision and drainage for recurrent abscesses 3
  • This approach has shown effectiveness with near-normal work status and fewer hospital days 3

Surgical Options (When Conservative Management Fails)

1. Minimally Invasive Techniques:

   • Sinusectomy or Gips procedure
   • Benefits: Faster recovery, better patient satisfaction, acceptable recurrence rates 2
   • Recommended as first-line surgical treatment over radical excision

2. Marsupialization:

   • Fistulotomy with marsupialization of the sinus tract or cyst wall
   • Low recurrence rate (4-6%) 4, 5
   • Can be performed as same-day surgery with minimal excision 5

3. Excision with Primary Closure:

   • Faster complete healing compared to open excision
   • Higher wound infection rate (14%) 4
   • Recurrence rate approximately 11% 4
   • Note: Midline closure should be avoided 2

4. Wide Excision with Secondary Healing:

   • Should be reserved only for grossly infected and complex cysts 4
   • Longer healing time
   • Recurrence rate approximately 13% 4

5. Flap Repairs:

   • For recurrent or persistent disease
   • Preferred by patients over healing by secondary intention 2
   • Examples include rhomboid plasty
   • Note: Infection rates can be high (40%) 6

Treatment Algorithm

1. First Presentation:

   • If acute abscess: Incision and drainage
   • If chronic disease: Conservative management with shaving and hygiene

2. Recurrent Disease:

   • If conservative management fails: Proceed to surgical options
   • First surgical choice: Minimally invasive techniques or marsupialization
   • For complex or recurrent cases: Consider flap repair

Important Considerations

• Pilonidal disease is associated with hidradenitis suppurativa, with patients having 4.97-5.61 times higher odds of developing pilonidal disease compared to controls 1
• Recurrence rates vary significantly between procedures (4-56%), with lay-open techniques having the highest recurrence rates 6
• The cosmetic result after surgery is often unsatisfactory, with only 42% of patients reporting satisfactory results 6
• Surgical treatment should focus on minimizing morbidity, recurrence, and healing time 4, 2

Follow-up Care

• Regular follow-up to monitor for recurrence
• Continue preventive measures (shaving, hygiene) even after successful treatment
• For recurrent disease at a previous site, search for local causes such as foreign material 1
• Culture recurrent abscesses and treat with appropriate antibiotics for 5-10 days 1

The trend in pilonidal disease management has shifted toward less invasive procedures with equivalent or better outcomes compared to classic excision techniques 2. When selecting a treatment approach, consider disease severity, patient preferences, and the balance between healing time, recurrence risk, and cosmetic outcomes.