Treatment of Pilonidal Abscess After Fall
The primary treatment for a pilonidal abscess that develops after a fall is surgical incision and drainage, which should be performed promptly to prevent expansion of the abscess and progression to systemic infection. 1
Initial Assessment and Management
- Evaluate for systemic inflammatory response syndrome (SIRS) signs: temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cell count >12,000 or <400 cells/µL 1
- Assess the extent of the abscess through physical examination, looking for pain, swelling, and erythema in the sacrococcygeal region 1
- The timing of surgical intervention should be based on the presence and severity of sepsis - emergent drainage is indicated for patients with sepsis, immunosuppression, diabetes mellitus, or diffuse cellulitis 1
- In the absence of these factors, surgical drainage should ideally be performed within 24 hours 1
Surgical Approach
- Incision and drainage is the cornerstone of treatment for pilonidal abscess 1
- The procedure can be performed under local anesthesia for small abscesses in fit, immunocompetent patients without systemic signs of infection 1
- For larger or more complex abscesses, or in patients with systemic symptoms, the procedure may require deeper anesthesia and inpatient management 1
- Several surgical techniques can be employed:
- Simple incision and drainage: Traditional approach but associated with high recurrence rates (>40%) 2
- Unroofing and curettage: Provides better healing rates and lower recurrence compared to simple drainage 2
- Marsupialization: Can be performed as a single-step procedure with high healing rates (95.3%) and moderate recurrence (14.6%) 3
- Endoscopic pilonidal abscess treatment (EPAT): A newer minimally invasive technique associated with reduced postoperative morbidity and quicker wound healing 4
Antibiotic Therapy
- Systemic antibiotics are generally not required for uncomplicated pilonidal abscesses after adequate surgical drainage 1
- Antibiotics should be administered if any of the following are present:
- When antibiotics are indicated, they should cover the common pathogens:
- For simple cases: An agent effective against Staphylococcus aureus 1
- For complex cases: Broad-spectrum coverage of Gram-positive, Gram-negative, and anaerobic bacteria 1
- If MRSA is suspected (based on local prevalence, prior colonization, or risk factors): Include coverage with vancomycin or another MRSA-active agent 1
Post-Procedure Care
- Regular wound care is essential for proper healing 3, 2
- Daily sitting in a warm tub together with douche may be recommended postoperatively 2
- Complete wound healing typically occurs within 4-10 weeks with proper care 3, 5
- Patients can usually return to normal activities within 7-13 days after treatment 2, 5
- The use of packing after drainage remains controversial - some practitioners place packing for hemostasis and to prevent premature skin closure, while others prefer catheter drainage or no packing 1
Prevention of Recurrence
- Recurrence rates vary by procedure type:
- For recurrent abscesses, search for local causes such as a persistent pilonidal cyst, foreign material, or inadequate drainage of the initial abscess 1
- Definitive treatment of the underlying pilonidal sinus disease may be required to prevent recurrence 2, 6
Special Considerations
- If the abscess developed after trauma (fall), assess for any foreign bodies or additional tissue damage that might complicate healing 1
- Patients with diabetes, immunosuppression, or other comorbidities may require more aggressive treatment and closer follow-up 1
- Imaging (CT, MRI) is not routinely required but may be helpful in complex cases or when recurrence is an issue 1