Treatment of Pilonidal Cyst
Incision and drainage is the primary treatment for acute pilonidal abscesses, followed by definitive surgical excision with either primary closure or marsupialization for chronic or recurrent disease. 1
Acute Pilonidal Abscess Management
Incision and drainage should be performed immediately for inflamed pilonidal cysts presenting as abscesses, as this is the recommended treatment for all cutaneous abscesses including pilonidal disease 1. This addresses the acute infection and provides symptomatic relief.
Adjunctive Antibiotic Therapy
- Antibiotics directed against S. aureus should be added if the patient exhibits systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cell count >12,000 or <4,000 cells/µL 1
- An antibiotic active against MRSA is recommended for patients with markedly impaired host defenses or those meeting SIRS criteria 1
- For patients without systemic signs, incision and drainage alone is sufficient without routine antibiotics 1
Definitive Surgical Management for Chronic/Recurrent Disease
Addressing Underlying Causes
A recurrent abscess at a previous site mandates evaluation for pilonidal cyst as a local predisposing factor, as eradication of the underlying pilonidal disease can be curative 1. This distinguishes pilonidal disease from simple recurrent skin abscesses.
Surgical Technique Selection
The choice of surgical approach should balance healing time, morbidity, and recurrence rates:
Excision with primary closure or marsupialization are the preferred surgical approaches for chronic pilonidal disease 2. These techniques offer the best balance of outcomes:
- Primary closure achieves fastest complete healing despite a 14% postoperative wound infection rate, with an 11% recurrence rate 2
- Marsupialization demonstrates the lowest recurrence rate at 4%, though healing time is intermediate 2
- Wide excision with open healing should be reserved only for grossly infected and complex cysts, as it has the longest healing time (average 76 days) despite a 13% recurrence rate 3, 2
Post-Surgical Wound Care
For wounds healing by secondary intention after surgical intervention:
- Implement appropriate mechanical or autolytic debridement, rinsing with antimicrobial solution, and adequate wound dressing as early as possible after surgery to prevent healing disturbances 3
- Patients should rinse the wound with clean water and dress with sterile compress during the healing phase 3
- Apply depilating cream to the wound borders to reduce hair accumulation and recurrence risk 4
Recurrence Prevention Strategies
A 5-day decolonization regimen should be considered for recurrent pilonidal abscesses, including:
- Twice-daily intranasal mupirocin 1
- Daily chlorhexidine washes 1
- Daily decontamination of personal items such as towels, sheets, and clothes 1
Hair removal in the sacrococcygeal area is critical, as hair is the causative agent in this acquired disease 5. Regular depilation reduces recurrence risk 4.
Alternative Approaches for Select Cases
Incision and curettage may be considered as an alternative to excision, particularly for less complex cases, offering favorable outcomes regarding morbidity, healing, recurrence, and cure 5. However, this approach has less robust evidence than excision-based techniques.
Laser or intense pulsed light (IPL) therapy may provide longer disease-free intervals in hirsute patients with recurrent disease, with some patients remaining recurrence-free for up to 36 months 6. This represents an emerging alternative to repeated surgical interventions in select cases.
Critical Pitfalls to Avoid
- Do not perform wide excision with secondary healing as first-line therapy unless dealing with grossly infected or complex cysts, as this significantly prolongs healing time without reducing recurrence rates 2
- Do not delay adequate wound care after surgery, as healing disturbances are common and early intervention with appropriate debridement and dressing prevents complications 3
- Do not ignore hair removal in the treatment plan, as failure to address the causative factor (hair penetration) leads to recurrence 4, 5