What is the recommended treatment for a 35-year-old woman with a pilonidal cyst?

Treatment of Pilonidal Cyst in a 35-Year-Old Woman

For a 35-year-old woman with a pilonidal cyst, incision and drainage is the recommended primary treatment if the cyst is inflamed or infected, followed by appropriate wound care to reduce recurrence. 1

Initial Assessment and Management

• Determine if the pilonidal cyst is:

  • Acutely inflamed/infected (painful, swollen, with or without drainage)
  • Chronic/recurrent (intermittent drainage from sinus tracts)
  • Asymptomatic (incidental finding)

• For inflamed or infected pilonidal cysts:

  • Incision and drainage is the first-line treatment
  • Antibiotics are generally NOT needed after successful drainage unless there are:
    • Systemic signs of infection (temperature >38.5°C, heart rate >110 beats/minute)
    • Signs of organ failure
    • Immunocompromised status 1

Surgical Options

Based on the current evidence, three main surgical approaches are available:

1. Excision with primary closure

   • Fastest healing time
   • 14% risk of postoperative wound infection
   • 11% recurrence rate 2

2. Marsupialization

   • Lower recurrence rate (4%)
   • Moderate healing time 2

3. Wide excision with secondary healing

   • Reserved for grossly infected and complex cysts
   • 13% recurrence rate
   • Longest healing time 2

Recommended Approach

For a 35-year-old woman with standard presentation:

1. First-line treatment: Excision with primary closure or marsupialization

   • These options offer the best balance between healing time, morbidity, and recurrence rates 2
   • For smaller wounds, direct midline suture is appropriate
   • For larger wounds, asymmetric closure techniques (Karydakis or Bascom procedures) are preferred 3

2. Avoid wide excision with secondary healing unless the cyst is grossly infected or complex, as this requires:

   • Prolonged wound care
   • Extended healing time
   • Temporary but prolonged cessation of activity 3

Perioperative Considerations

• If prophylactic antibiotics are deemed necessary (based on infection severity or host factors), consider:
  • Single-dose intravenous metronidazole (500 mg) preoperatively 1
  • Cultures are not routinely recommended unless:
    • Patient has systemic signs of infection
    • Patient is immunocompromised
    • Previous treatment failure has occurred 1

Post-Procedure Care

• Meticulous wound care is essential regardless of surgical approach
• Hair removal in the sacrococcygeal region to prevent recurrence
• Regular follow-up to monitor for wound healing and recurrence

Management of Recurrent Disease

If recurrence develops:

• Search for local causes such as foreign material or persistent hair
• Early drainage and culture of recurrent abscesses
• Consider a 5-10 day course of antibiotics active against cultured pathogens 1

The choice between surgical options should prioritize minimizing recurrence risk while considering healing time and the impact on the patient's quality of life, as pilonidal disease commonly affects young, active individuals.