What is the treatment for a pilonidal cyst?

Treatment of Pilonidal Cysts

Incision and drainage is the primary treatment for inflamed pilonidal cysts, with subsequent wound management either by open healing (secondary intention) or closed healing (primary closure). 1

Initial Management

• Pilonidal cysts are typically managed surgically through incision and drainage, which allows for thorough evacuation of pus and breaking up of loculations within the cavity 1
• The procedure should be performed early in the course of infection, especially for recurrent abscesses at previous infection sites 1
• Gram stain and culture of the drainage are not routinely recommended unless there are signs of systemic infection 2

Post-Surgical Wound Management

• After surgical drainage, the wound can be managed in one of two ways:
  • Open wound healing (secondary intention): Simply covering the surgical site with a dry dressing 1
  • Closed wound healing (primary closure): Suturing the wound closed 1
• Packing the wound with gauze is generally not recommended as it can cause more pain without improving healing outcomes 2
• An adequate wound care regimen including appropriate wound debridement, rinsing, and dressing changes is essential for optimal healing 3

Antibiotic Therapy

• Systemic antibiotics are generally unnecessary for uncomplicated pilonidal cysts after incision and drainage 1
• Antibiotics should only be considered if there is:
  • Extensive surrounding cellulitis 1
  • Signs of systemic infection (temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or abnormal white blood cell count) 2
• If antibiotics are deemed necessary, they should target Staphylococcus aureus, which is a common pathogen 2
• For recurrent pilonidal abscesses, a 5-10 day course of antibiotics active against the cultured pathogen may be considered 1

Management of Recurrent Cases

• For recurrent infections at the same site, complete excision of the cyst and its wall should be considered once the acute inflammation has resolved 2
• Different surgical techniques have been proposed for recurrent cases, with the goal of reducing morbidity, promoting fast healing, and preventing further recurrence 4

Special Considerations

• Histological examination of all excised pilonidal cyst tissue is essential, as malignant degeneration can occur (though rare, with an estimated incidence of 0.1%) 5
• The most common type of malignancy arising from pilonidal cysts is squamous cell carcinoma, which requires wider excision if suspected 5
• Chronic, recurrent pilonidal cysts that have been present for many years warrant particular attention due to the risk of malignant transformation 6

Common Pitfalls to Avoid

• Avoid closing the wound without adequate drainage, as this may lead to recurrent infection 2
• Do not routinely prescribe antibiotics unless there are signs of systemic infection 2
• Never ignore unusual growth or changes in a chronic pilonidal cyst, as this could indicate malignant transformation 6