Treatment of Pilonidal Cysts
Incision and drainage is the primary treatment for inflamed pilonidal cysts, followed by appropriate wound management and consideration for definitive surgical excision once inflammation resolves. 1
Initial Management
- Incision and drainage (I&D) is the cornerstone treatment for acute, inflamed pilonidal cysts to evacuate pus and break up loculations 1
- After surgical drainage, the wound can be managed in one of two ways:
- Packing the wound with gauze is not recommended as it causes more pain without improving healing outcomes 2
Antibiotic Therapy
- Systemic antibiotics are generally unnecessary for uncomplicated pilonidal cysts after I&D unless there is extensive surrounding cellulitis or systemic signs of infection 1
- Signs of systemic infection warranting antibiotics include: temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12,000 or <400 cells/µL 2
- For recurrent pilonidal abscesses, a 5-10 day course of antibiotics active against the cultured pathogen may be considered 1
Definitive Treatment
- For recurrent pilonidal cysts at the same site, complete excision of the cyst and its wall is recommended once acute inflammation has resolved 2
- Several surgical techniques exist for definitive treatment:
- Excision with open healing (secondary intention)
- Excision with primary closure
- Incision and curettage 3
Post-Surgical Wound Care
- An adequate wound care regimen after surgery includes:
- Appropriate wound debridement
- Rinsing with antimicrobial solution
- Topical treatments to promote healing
- Appropriate dressing selection 4
- Complete wound closure typically occurs within an average of 76 days with proper wound care 4
Special Considerations
- Histological examination of all excised pilonidal cyst tissue is essential, as malignant transformation can occur in rare cases (estimated at 0.1% of cases) 5
- Squamous cell carcinoma is the most common malignancy associated with chronic pilonidal disease 6
- Chronic, recurrent pilonidal cysts with long-standing inflammation (especially those present for many years) should raise suspicion for potential 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 a pilonidal cyst that changes in appearance, grows rapidly, or fails to heal properly, as these could be signs of malignant transformation 5, 6