Treatment Options for Pilonidal Cysts
Surgical excision is the primary treatment for pilonidal cysts, with the choice of technique depending on the complexity and presentation of the cyst. The most effective approaches include excision with primary closure for simple cases and marsupialization for more complex presentations.
Diagnosis and Assessment
- Pilonidal cysts (also called pilonidal sinus) typically present in the sacrococcygeal region
- Symptoms may include:
- Pain and tenderness in the affected area
- Swelling and redness
- Drainage of pus or blood if infected
- Foul odor from the draining fluid
Treatment Algorithm
1. Non-Infected Pilonidal Cysts
- Complete surgical excision is the recommended treatment
- Options include:
2. Infected/Inflamed Pilonidal Cysts
- Incision and drainage is the primary treatment 2
- Complete evacuation of pus and probing to break loculations
- Antibiotics are rarely necessary unless there is:
- Extensive surrounding cellulitis
- Multiple lesions
- Severely impaired host defenses
- Severe systemic manifestations 2
3. Post-Procedure Management
- Proper wound care with regular dressing changes
- Monitoring for signs of continued infection
- Follow-up within 7-14 days to assess healing 2
Surgical Techniques Comparison
| Technique | Advantages | Disadvantages | Recurrence Rate |
|---|---|---|---|
| Excision with primary closure | Fastest healing time | 14% infection rate | 11% [1] |
| Marsupialization | Lowest recurrence rate | Longer healing time | 4% [1] |
| Wide excision with secondary healing | Good for complex/infected cysts | Longest healing time | 13% [1] |
Factors Affecting Treatment Choice
- Complexity of the cyst: Simple vs. complex with multiple tracts
- Presence of infection: Infected cysts require drainage before definitive treatment
- Previous recurrences: May require more aggressive surgical approach
- Patient factors: Age, comorbidities, and ability to manage wound care
Common Pitfalls to Avoid
- Incomplete removal of the cyst wall is the main cause of recurrence
- Misdiagnosing inflammation as infection can lead to unnecessary antibiotic use 2
- Inadequate drainage of infected cysts can lead to persistent symptoms
- Failure to consider other diagnoses like furuncles can lead to inappropriate management 2
Long-Term Considerations
- Recurrence rates range from 4-13% depending on the surgical technique used 1
- Complete healing was fastest in the primary closure group despite a higher postoperative wound infection rate 1
- For recurrent pilonidal cysts, radical excision with primary closure and drainage of the depths of the wound has shown good long-term results 3
Based on the available evidence, excision with primary closure offers the fastest healing time for simple cases, while marsupialization provides the lowest recurrence rate and is better suited for more complex presentations.