What is the recommended management for a patient with a persistent, intermittently irritated cyst near the gluteal cleft?

Management of a Pilonidal Cyst in the Gluteal Cleft

Surgical referral for complete excision is the recommended management for this patient's persistent, intermittently irritated pilonidal cyst in the gluteal cleft to prevent complications including infection, abscess formation, and rare malignant transformation.

Clinical Assessment and Diagnosis

Based on the patient's description, the lesion is most consistent with a pilonidal cyst:

• Location in the gluteal cleft ("buttock crack")
• 5-year history of intermittent irritation
• Current tenderness to touch
• History of manipulation (picking at it)

This presentation is typical of pilonidal cyst disease, which predominantly affects the natal cleft of the buttocks and is characterized by:

• Initial asymptomatic phase followed by complications such as pain and discharge 1
• Predilection for males (3-4:1 male-to-female ratio) 1
• Often presents in young adults 1

Management Recommendations

Primary Management

1. Surgical referral for excision:
   • Complete surgical excision is the definitive treatment for pilonidal cysts 2
   • This approach addresses both current symptoms and prevents future complications

Surgical Options

Two main surgical approaches exist:

• Complete excision with either:
  • Open wound healing (lower recurrence but longer healing time)
  • Closed wound healing (faster healing but potentially higher recurrence)
• Incision and curettage (less invasive alternative with good outcomes) 2

The specific surgical technique should be determined by the surgeon based on:

• Size of the cyst
• Presence of sinus tracts
• Patient factors including body habitus and activity level

Rationale for Surgical Management

Preventing Complications

1. Infection and abscess formation:

   • Untreated pilonidal cysts commonly develop infections requiring more extensive treatment
   • If abscess develops, incision and drainage becomes necessary with systemic antibiotics 3

2. Recurrence:

   • Pilonidal disease has a high recurrence rate (up to 50%) if not properly managed 4
   • Complete excision with appropriate technique reduces recurrence risk

3. Rare but serious risk of malignant transformation:

   • Long-standing, chronic pilonidal cysts can undergo malignant transformation to squamous cell carcinoma 4
   • This rare complication carries a poor prognosis with only 55% 5-year survival rate 4

Important Considerations

Pre-surgical Assessment

• Imaging: Not routinely required for typical presentations but may be considered for:
  • Unusually large cysts
  • Atypical presentations
  • Suspicion of deeper extension

Pathology Examination

• All excised tissue should undergo pathological examination to:
  • Confirm diagnosis
  • Rule out malignancy
  • Document size, wall thickness, contents, and presence of solid areas 3

Follow-up Care

• Clinical assessment within 48-72 hours after surgical treatment to evaluate healing 3
• Patient education on wound care and prevention strategies:
  • Proper hygiene of the gluteal area
  • Hair removal in the affected area
  • Avoiding prolonged sitting

Differential Diagnosis

Other conditions that may present similarly include:

• Epidermal inclusion cyst 5
• Hidradenitis suppurativa
• Perianal abscess
• Müllerian-type cutaneous ciliated cyst (rare) 6

Caution

While the patient's current urinalysis shows trace protein and trace blood, these findings are not directly related to the pilonidal cyst and should be evaluated separately as they may indicate a different clinical issue requiring attention.