What is the treatment for a pilonidal cyst?

Treatment of Pilonidal Cysts

Incision and drainage is the primary intervention for infected or inflamed pilonidal cysts, followed by appropriate wound care to promote healing by secondary intention. 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 Infected/Inflamed Pilonidal Cyst

• First-line treatment: Incision and drainage
  • Thorough evacuation of pus
  • Probing of the cavity to break up loculations
  • Application of dry dressing 1

2. Antibiotic Therapy

• Indications for systemic antibiotics:

  • Temperature >38.5°C
  • Heart rate >110 beats/minute
  • Signs of organ failure
  • Extensive surrounding cellulitis
  • Severely impaired host defenses 1

• Prophylactic antibiotics:

  • Generally not required after successful drainage
  • Consider single-dose intravenous metronidazole (500 mg) preoperatively in selected cases 1

3. Post-Drainage Management

• Wound care regimen:

  • Appropriate mechanical or autolytic debridement
  • Rinsing with antimicrobial solution
  • Application of appropriate dressings 2
  • Regular follow-up to monitor healing

• Cultures:

  • Not routinely recommended unless:
    • Patient has systemic signs of infection
    • Patient is immunocompromised
    • Previous treatment failure 1

4. Definitive Treatment for Recurrent Cases

• Surgical options:

  • Complete excision of the cyst (with open or closed wound healing)
  • Incision and curettage 3

• For recurrent disease:

  • Search for local causes such as foreign material or persistent hair
  • Consider 5-10 day course of antibiotics active against cultured pathogens 1
  • More extensive surgical intervention may be needed

Prevention of Recurrence

• Regular hair removal in the affected area
• Maintaining good hygiene
• Avoiding prolonged sitting
• Weight loss if applicable

Important Considerations

• Complete wound closure after surgical intervention typically takes an average of 76 days 2
• Histological examination of all excised pilonidal cyst tissue is essential to rule out rare malignant transformation (0.1% of cases) 4
• Pilonidal cysts are generally considered an acquired condition rather than congenital, with hair being the primary causative agent 3

Caution

• Failure to properly drain and treat infected pilonidal cysts can lead to extensive infection, abscess formation, and significant scarring
• Inadequate wound care after drainage can result in poor healing and increased risk of recurrence
• Malignant degeneration, though rare, should be considered in chronic, non-healing cases