What are the treatment options for pilonidal cysts?

Treatment Options for Pilonidal Cysts

The most effective treatment for pilonidal cysts depends on the severity of the condition, with surgical excision being the primary treatment option for non-inflamed cysts and incision and drainage for inflamed or infected cysts.

Understanding Pilonidal Cysts

Pilonidal cysts are chronic intermittent disorders of the sacrococcygeal region that form when hair penetrates the skin and creates a foreign body reaction with chronic inflammation. They typically occur in the natal cleft (the groove between the buttocks) and can become painful, especially when infected.

Diagnostic Considerations

• Look for a small pit or dimple in the midline of the sacrococcygeal region
• Check for signs of inflammation: redness, swelling, pain, and tenderness
• Assess for purulent drainage which may indicate infection
• Determine if there are systemic symptoms like fever (suggesting infection)

Treatment Algorithm

1. For Inflamed/Infected Pilonidal Cysts:

• Incision and drainage is the primary treatment 1
• Complete evacuation of pus and probing to break loculations
• Systemic antibiotics are rarely necessary unless there is:
  • Extensive surrounding cellulitis
  • Multiple lesions
  • Severely impaired host defenses
  • Severe systemic manifestations (temperature >38.5°C, heart rate >110 beats/minute) 1

2. For Non-Inflamed Pilonidal Cysts:

• Complete surgical excision is recommended 1, 2
• Surgical options include:
  • Excision with primary closure (fastest healing but 14% infection rate, 11% recurrence) 2
  • Marsupialization (4% recurrence rate) 2
  • Wide excision with secondary healing (13% recurrence rate) - reserved only for grossly infected and complex cysts 2

3. Alternative Treatments:

• Laser therapy - Diode laser or intense pulsed light (IPL) treatments have shown promising results with longer disease-free intervals 3
• Minimally invasive techniques - CO2 laser punch-assisted surgery or two-step laser procedures for cosmetically sensitive areas 1
• Simple day-case surgery - Removal of midline skin pits with lateral drainage of the abscess and sinus, without wide excision 4

Post-Treatment Care

• Proper wound care is essential after any procedure
• For open wounds:
  • Regular cleaning with antimicrobial solution
  • Appropriate mechanical or autolytic debridement if needed
  • Consider haemoglobin spray application to promote healing 5
• Schedule follow-up within 7-14 days to assess wound healing 1
• Monitor for signs of infection or recurrence

Special Considerations

• Hirsute patients have higher recurrence rates and may benefit from:
  • Hair removal in the affected area
  • Flattening of the natal cleft with off-midline skin closure 4
• Recurrent disease may require more aggressive surgical approaches
• Complex cysts might need specialized surgical techniques

Potential Complications

• Wound infection (up to 14% with primary closure) 2
• Recurrence (4-13% depending on surgical technique) 2
• Delayed healing, especially with wide excision
• Scarring and cosmetic concerns

Prevention of Recurrence

• Regular hair removal from the natal cleft area
• Maintaining good hygiene
• Weight management if obesity is a contributing factor
• Avoiding prolonged sitting

By following this treatment algorithm based on the nature of the pilonidal cyst (inflamed vs. non-inflamed), patients can achieve optimal outcomes with minimal recurrence rates.