What are the treatment options for pilonidal cysts?

Treatment Options for Pilonidal Cysts

Incision and drainage is the recommended primary treatment for inflamed or infected pilonidal cysts, followed by appropriate wound care and preventive measures to reduce recurrence. 1

Clinical Presentation

Pilonidal cysts typically present with:

• Pain and tenderness in the sacrococcygeal region
• Swelling and redness over the affected area
• Drainage of purulent material if infected
• Possible fever if systemic infection is present
• Intense pruritus ani in some cases

Treatment Algorithm

1. Acute Management

• For infected/inflamed cysts:

  • Incision and drainage is the primary intervention
  • Thorough evacuation of pus and probing of cavity to break up loculations
  • Simply covering the surgical site with a dry dressing is usually effective 2
  • Gram stain, culture, and systemic antibiotics are rarely necessary for uncomplicated cases

• Antibiotic indications (limited to):

  • Systemic signs of infection (SIRS, temperature >38.5°C, heart rate >110 beats/minute)
  • Signs of organ failure
  • Presence of extensive surrounding cellulitis
  • Severely impaired host defenses 2, 1

2. Definitive Surgical Management

Three main approaches based on clinical evidence:

1. Excision with primary closure:

   • Fastest complete healing time
   • 14% postoperative wound infection rate
   • 11% recurrence rate 3

2. Wide excision without closure (open technique):

   • Longer healing time
   • 13% recurrence rate
   • Should be reserved for grossly infected and complex cysts 3

3. Marsupialization:

   • Moderate healing time
   • Lowest recurrence rate (4%) 3
   • Good option for most patients

3. Post-Surgical Wound Care

For wounds healing by secondary intention:

• Appropriate mechanical or autolytic debridement
• Rinsing with antimicrobial solution
• Adequate wound dressing
• Consider hemoglobin spray application (shown to achieve complete wound closure within an average of 76 days) 4

4. Recurrence Prevention

• Regular removal of hair in the affected area
• Consider depilating creams for the border of the wound 5
• Maintain good hygiene in the sacrococcygeal region
• For recurrent disease, search for local causes such as foreign material or persistent hair 1

Alternative Treatments for Recurrent Cases

• Laser and light treatments:

  • Diode laser or intense pulsed light (IPL) treatments have shown promising results
  • Can provide longer disease-free intervals and fewer recurrences compared to traditional surgical interventions 6

• Collagen and silver sulfadiazine treatment:

  • For relapsed cases, open treatment with heterologous lyophilized collagen and silver sulfadiazine
  • Effective for relapses with healing periods between 4 weeks and 2 months 5

Treatment Selection Considerations

• For first-time presentations, excision with primary closure or marsupialization is preferred based on healing time and recurrence rates
• For complex or grossly infected cysts, wide excision with secondary healing may be necessary
• For recurrent cases, consider alternative approaches including laser/light treatments or specialized wound care

Pitfalls and Caveats

• Cultures are not routinely recommended unless the patient has systemic signs of infection, is immunocompromised, or has experienced previous treatment failure 1
• Relying solely on antibiotics without adequate drainage is ineffective
• Inadequate hair removal and poor wound care are major contributors to recurrence
• Healing time can be prolonged with the open technique, affecting patient quality of life

The optimal approach should be selected based on the severity of infection, complexity of the cyst, and whether it's a recurrent case, with the goal of minimizing morbidity and preventing recurrence.