What is the treatment for an infected pilonidal cyst or sinus?

Treatment of Infected Pilonidal Cyst or Sinus

The primary treatment for an infected pilonidal cyst or sinus is incision and drainage followed by appropriate antibiotic therapy, with definitive surgical excision once the acute infection resolves. 1

Initial Management of Infected Pilonidal Cyst

Incision and Drainage

• Incision and drainage is the cornerstone of treatment for inflamed and infected pilonidal cysts/sinuses 1
• This procedure should be performed promptly to relieve pain and prevent further spread of infection
• The procedure involves:
  • Local anesthesia of the area
  • Incision over the most fluctuant part of the abscess
  • Complete drainage of purulent material
  • Breaking up of loculations if present
  • Gentle packing of the cavity (if needed)

Antibiotic Therapy

• Antibiotics should be administered based on the severity of infection:
  • For mild infections without systemic symptoms: antibiotics may not be necessary after adequate drainage 1
  • For moderate to severe infections with systemic inflammatory response syndrome (SIRS): antibiotics active against skin flora are indicated 1

Recommended Antibiotic Regimens:

• First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 2
• For penicillin allergic patients:
  • Cefdinir 300-600 mg twice daily for 5-7 days
  • Cefuroxime 250-500 mg twice daily for 5-7 days
  • Doxycycline (if severe penicillin allergy) 2

Definitive Treatment Options

After the acute infection resolves, definitive treatment should be considered to prevent recurrence:

Surgical Options

1. Excision with primary closure:

   • Asymmetric excision with primary closure using suction drain and subcuticular skin closure has shown excellent results 3
   • Benefits include shorter healing time (average 13.2 days) and earlier return to normal activities 3
   • Complication rate of approximately 7% with this technique 3

2. Excision with open healing:

   • May be preferred in cases with extensive infection or recurrent disease
   • Requires longer healing time and more follow-up visits 4
   • Patients left open require more follow-up visits (average 6.48 vs 4.18) and more operative procedures (1.71 vs 1.25) compared to primary closure 4

3. Excision with flap closure:

   • Used for complex or recurrent cases
   • No significant difference in wound breakdown between midline and flap closure 4
   • Infection rates tend to be lower with flap closure compared to midline closure (11% vs 20%) 4

Follow-up Care

• Regular wound assessment until complete healing
• Wound care instructions:
  • Keep area clean and dry
  • Avoid prolonged sitting
  • Hair removal from the area (shaving or laser hair removal)
• Monitor for signs of recurrent infection:
  • Increased pain, swelling, or drainage
  • Fever or systemic symptoms

Prevention of Recurrence

• Regular hair removal from the sacrococcygeal area
• Maintain good hygiene
• Weight loss if overweight
• Avoid prolonged sitting

Common Pitfalls and Caveats

1. Inadequate drainage: Ensure complete drainage of all loculations to prevent persistent infection
2. Premature definitive surgery: Perform definitive surgical excision only after acute infection has completely resolved
3. Failure to address contributing factors: Hair removal and hygiene are essential for preventing recurrence
4. Overlooking systemic symptoms: Patients with fever, tachycardia, or other signs of systemic infection require more aggressive antibiotic therapy and closer monitoring
5. Inappropriate antibiotic selection: Culture the drainage material in recurrent cases to guide antibiotic selection

For recurrent pilonidal disease, a more aggressive surgical approach may be necessary, with consideration of flap procedures to flatten the natal cleft and move the surgical scar away from the midline 3.