Pilonidal Cysts Do Not Resolve on Their Own
Pilonidal cysts are an acquired inflammatory disease that require intervention and do not spontaneously resolve—they must be treated surgically or will persist and potentially develop complications. 1, 2
Natural History Without Treatment
Pilonidal disease is caused by hair penetration into the skin and represents an acquired inflammatory process that will not self-resolve. 2 The embedded hair acts as a foreign body that perpetuates chronic inflammation and sinus tract formation.
Untreated pilonidal cysts initially may be asymptomatic but inevitably progress to complications including abscess formation, chronic draining sinuses, pain, and discharge. 3 This is not a condition that "runs its course"—it requires definitive management.
Without surgical intervention, patients develop chronic wounds and draining sinuses that cause long-term morbidity, disability, and decreased quality of life. 4
Why Intervention Is Necessary
The pathophysiology involves hair shafts acting as foreign bodies that create persistent inflammation with multinucleated giant cells and sinus tract formation. 3 This process cannot resolve while the inciting hair remains embedded in the tissue.
Recurrent abscesses at the same site indicate local factors (such as pilonidal cyst) that require eradication to achieve cure. 1 Simply draining an acute abscess without addressing the underlying pilonidal disease leads to recurrence.
Treatment Outcomes and Timeline
Even with optimal surgical excision, complete wound closure takes an average of 76 days (range 23-98 days) when healing by secondary intention. 5 This represents the healing time after definitive surgical treatment, not spontaneous resolution.
Recurrence rates after surgical treatment are substantial—approximately 33% overall, with 80% of recurrences occurring within the first year. 4 This high recurrence rate after surgery underscores that without any treatment, the disease will persist indefinitely.
Obesity (BMI ≥95th percentile) is independently associated with higher recurrence rates even after surgical excision. 4
Clinical Pitfall to Avoid
Do not counsel patients that pilonidal cysts will resolve with conservative management or observation alone. The disease requires surgical intervention as the primary treatment method. 2 Delaying definitive treatment only allows progression to more complicated disease with chronic draining sinuses and increased morbidity.