What are the diagnosis and treatment options for a pilonidal cyst?

Diagnosis and Treatment of Pilonidal Cysts

Incision and drainage is the primary intervention for infected or inflamed 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 1

Diagnostic Approach

1. Physical examination: Inspect the sacrococcygeal region for:

   • Midline pits or openings in the natal cleft
   • Presence of hair in the sinus tract
   • Signs of inflammation or infection (redness, swelling, tenderness)
   • Purulent discharge

2. Imaging: Not routinely required but may be useful in complex or recurrent cases:

   • MRI can help identify the extent of disease, particularly with complex or recurrent cases 2
   • Ultrasound may be used to identify fluid collections or abscesses

3. Histological examination:

   • All excised pilonidal cyst specimens should undergo histological examination
   • This is essential to rule out rare malignant degeneration (0.1% incidence of squamous cell carcinoma) 3

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

• Antibiotic therapy:

  • Not routinely required after successful drainage
  • Indicated only when:
    • Systemic signs of infection present (temperature >38.5°C, heart rate >110 beats/minute)
    • Signs of organ failure
    • Extensive surrounding cellulitis
    • Severely impaired host defenses 1

2. Chronic or Recurrent Pilonidal Disease

• Surgical options:

  1. Excision with primary closure:

     • Faster healing time
     • Higher wound infection rate (14%)
     • Recurrence rate approximately 11% 4

  2. Marsupialization:

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

  3. Wide excision with secondary healing:

     • Reserved for grossly infected and complex cysts
     • Longer healing time
     • Recurrence rate approximately 13% 4

• Post-surgical wound management:

  • Appropriate mechanical or autolytic debridement
  • Rinsing with antimicrobial solution
  • Consideration of hemoglobin spray application
  • Proper primary and secondary dressings 5

3. Alternative Treatments

• Laser and light treatments:
  • Diode laser or intense pulsed light (IPL) therapy
  • May provide longer disease-free intervals
  • Particularly useful for patients with hirsutism
  • Can reduce recurrence rates compared to traditional surgical interventions 6

Prevention of Recurrence

1. Hair removal:

   • Regular shaving or laser hair removal in the affected area
   • Particularly important for hirsute patients

2. Hygiene measures:

   • Regular cleaning of the sacrococcygeal area
   • Avoidance of prolonged sitting

3. Follow-up care:

   • Regular assessment for early signs of recurrence
   • Prompt intervention if recurrence is suspected

Special Considerations

• Recurrent disease: Search for local causes such as foreign material or persistent hair 1

• Immunocompromised patients: May require more aggressive antibiotic therapy and closer monitoring 1

• Malignant transformation: Though rare (0.1%), any suspicious lesion should undergo wide excision and thorough histological examination 3

By following this structured approach to diagnosis and treatment, most patients with pilonidal disease can achieve complete healing with minimal risk of recurrence.