What is the recommended management for a small pilonidal cyst?

Management of Small Pilonidal Cysts

For small pilonidal cysts, conservative management is the recommended first-line approach, including meticulous hair control through natal cleft shaving, improved perineal hygiene, and only proceeding to incision and drainage if the cyst becomes inflamed or infected.

Conservative Management Approach

Conservative management is highly effective for small pilonidal cysts and should be the initial treatment of choice. This approach includes:

• Hair control: Regular shaving or hair removal of the natal cleft area to prevent further hair penetration into the sinus
• Improved hygiene: Thorough cleaning of the affected area with mild soap and water
• Avoiding pressure: Minimizing prolonged sitting and pressure on the affected area
• Warm compresses: Application to relieve discomfort and potentially help with drainage

This conservative approach has been shown to effectively control pilonidal disease in the outpatient setting while promoting near-normal work status and avoiding unnecessary surgical procedures 1.

When to Consider Intervention

Intervention is indicated when a pilonidal cyst becomes:

1. Inflamed
2. Infected (abscess formation)
3. Significantly painful
4. Recurrent despite conservative measures

For inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles, incision and drainage is the recommended treatment 2. This applies to pilonidal cysts that have become inflamed or infected.

Surgical Options for Symptomatic Cysts

When conservative management fails and the cyst becomes symptomatic, the following surgical options may be considered:

1. Incision and drainage: For acutely inflamed/infected cysts
2. Excision with primary closure: Faster healing but has approximately 11% recurrence rate 3
3. Marsupialization: Lower recurrence rate (approximately 4%) 3
4. Wide excision with secondary healing: Reserved only for grossly infected and complex cysts 3

Follow-up and Recurrence Prevention

After treatment, ongoing preventive measures are essential:

• Continue regular hair removal from the natal cleft area
• Maintain meticulous hygiene
• Consider a 5-day decolonization regimen for recurrent infections, including daily chlorhexidine washes 2
• Follow up if symptoms recur or worsen

Special Considerations

• Recurrent cysts: A recurrent abscess at a previous infection site should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material 2
• Histological examination: While rare (0.1% incidence), malignant degeneration can occur in pilonidal cysts. Consider histological examination of excised tissue, especially in long-standing or atypical cases 4

Conclusion

Small, asymptomatic pilonidal cysts should be managed conservatively with meticulous hair control and improved hygiene. Surgical intervention should be reserved for cases that become symptomatic, with the specific technique chosen based on the extent of disease, patient factors, and surgeon expertise.