What are the treatment options for pilonidal cysts?

Treatment Options for Pilonidal Cysts

Incision and drainage is the recommended primary treatment for inflamed or draining pilonidal cysts, followed by appropriate wound care to promote healing. 1

Initial Management of Symptomatic Pilonidal Cysts

• For inflamed, draining pilonidal cysts, incision and drainage is the cornerstone of treatment to relieve symptoms and promote healing 1
• After drainage, the wound should be covered with a dry dressing rather than packed with gauze, as packing causes more pain without improving healing outcomes 1
• Systemic antibiotics are generally unnecessary unless there are signs of systemic infection (temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or abnormal white blood cell count) 1

Definitive Surgical Management Options

• Excision with primary closure: Offers fastest healing time but has approximately 11-14% recurrence rate and potential for wound infection 2
• Wide excision without closure: Results in slower healing and has approximately 13% recurrence rate 2
• Marsupialization: Shows lower recurrence rates (approximately 4%) with moderate healing time 2
• Excision with drain placement: Some studies report successful outcomes using a drain for antiseptic wound flushing after excision and primary closure 3

Post-Surgical Wound Care

• Proper wound care after surgical intervention is critical to prevent healing disturbances and recurrence 4
• Recommended wound care regimen includes:
  • Appropriate mechanical or autolytic debridement of the wound
  • Rinsing with antimicrobial solution
  • Application of appropriate dressings 4
• Complete wound closure can typically be achieved within an average of 76 days with proper wound care 4

Alternative Treatment Approaches

• Laser and intense pulsed light (IPL) treatments have shown promise as alternatives to traditional surgical intervention, particularly for patients with hirsutism who experience recurrent pilonidal cysts 5
• These technologies may provide longer disease-free intervals and fewer recurrences compared to traditional approaches 5

Common Pitfalls to Avoid

• Avoid closing the wound without adequate drainage, as this may lead to recurrent infection 1
• Do not routinely prescribe antibiotics unless there are signs of systemic infection 1
• For recurrent pilonidal cysts, consider complete excision of the cyst and its wall once acute inflammation has resolved 1
• Wide excision with secondary healing should be reserved only for grossly infected and complex cysts 2

Treatment Selection Algorithm

1. For acute, inflamed cysts: Perform incision and drainage with simple wound coverage 1
2. For chronic or recurrent cysts: Consider definitive surgical management based on:
   • Patient factors (hirsutism, obesity, occupation)
   • Complexity of the cyst (simple vs. complex with multiple tracts)
   • Select from: excision with primary closure (fastest healing), marsupialization (lowest recurrence), or laser/IPL for hirsute patients 2, 5
3. For complex, extensively infected cysts: Consider wide excision with secondary healing 2