What is the treatment for a pilonidal sinus?

Treatment of Pilonidal Sinus

The most effective treatment for pilonidal sinus disease requires a combination of surgical intervention and appropriate wound care, with the specific approach depending on disease severity and patient factors. 1, 2

Understanding Pilonidal Sinus Disease

Pilonidal sinus is a chronic infection of the hairy skin, most commonly located in the natal cleft (buttock crease). It significantly impacts quality of life and requires treatment tailored to the patient's specific condition. 1

Key characteristics include:

• Formation of a sinus tract lined by stratified squamous epithelium 2
• Often presents with multiple sinuses with lateral openings 2
• Presentation ranges from asymptomatic pits to painful draining lesions 2

Treatment Options

1. Asymptomatic Disease

• Asymptomatic pits do not require treatment 2

2. Acute Pilonidal Abscess

• Options include aspiration, drainage without curettage, or drainage with curettage 2
• Drainage is the primary initial treatment for acute abscess 2
• Early excision of the pilonidal pit at the time of abscess treatment reduces the high (40%) risk of subsequent sinus formation 3

3. Chronic or Recurrent Disease

Three main treatment approaches exist:

A. Excision with Open Wound Healing (Secondary Intention)

• Considered the standard treatment with low recurrence rates 1
• Requires significant wound care and leads to prolonged time off work 1
• Median healing time of 8-10 weeks 4
• Infection rates around 1.8% 5

B. Minimally Invasive Techniques

• Includes pit picking, fistuloscopy, phenol injection, and laser treatment 1
• Preserves most of the skin 1
• Final evaluation of long-term results is still pending 1

C. Excision with Plastic Reconstruction (Primary Closure)

• Technically demanding and often requires inpatient treatment 1
• Leads to good long-term results 1
• Patients return to work earlier than with open healing 5
• Slightly higher infection rates (3.6%) and recurrence rates (4.4%) compared to open healing 5
• Primary closure with a lateral approach appears to give the best results 2

Advanced Wound Care Considerations

• Negative pressure wound therapy (NPWT) may be beneficial for wounds healing by secondary intention 4
• Average healing time with NPWT is 9.8 weeks compared to 15.0 weeks with conventional dressings, though this difference was not statistically significant 4
• Recurrence rates may be lower with NPWT (3.1%) compared to conventional dressings (12.5%) 4

Risk Factors for Poor Healing

• Comorbidities significantly affect healing time 4
• Specific risk factors include:
  • Morbid obesity (BMI ≥35) 4
  • Chronic infective skin conditions 4
  • Immunomodulating drugs or chemotherapy 4

Treatment Algorithm

1. Assess presentation:

   • Asymptomatic: No treatment required 2
   • Acute abscess: Drainage procedure 2
   • Chronic or recurrent disease: Proceed to surgical options 1, 2

2. For chronic/recurrent disease, consider patient factors:

   • Employment status and need to return to work quickly: Consider primary closure 5
   • Presence of comorbidities: May require more aggressive approach 4
   • Extent of disease: Larger or more complex disease may benefit from plastic reconstruction 1

3. Surgical approach based on disease severity:

   • Limited disease: Consider minimally invasive techniques 1
   • Moderate disease: Excision with primary closure (preferably with lateral approach) 2
   • Extensive disease: Wide excision with appropriate reconstruction 1

4. Wound management:

   • For open wounds: Consider NPWT to potentially reduce healing time and recurrence 4
   • Regular follow-up to monitor healing progress 4

Important Considerations

• Treatments that flatten the natal cleft reduce recurrence risk by half 3
• En bloc excision with secondary healing should be avoided in favor of more modern approaches 3
• Recurrence rates vary with technique, operator experience, and length of follow-up 2
• Complete follow-up is essential as recurrence can occur years after initial treatment 3