What is the management for a 25-year-old male with a suspected pilonidal cyst (primary diagnosis) presenting with a subcutaneous bump around the coccyx (tail bone) and pain when sitting for 3 days?

Management of Suspected Pilonidal Cyst in a 25-Year-Old Male

Incision and drainage is the definitive treatment for this acute pilonidal abscess, and should be performed promptly to relieve pain and drain the infected collection. 1

Differential Diagnosis

When evaluating a subcutaneous bump near the coccyx with tenderness to palpation and pain with sitting, consider:

• Pilonidal cyst/abscess (primary diagnosis) - acquired inflammatory disease from hair penetration into skin, most common in young males 2, 3
• Perirectal abscess - would typically present closer to the anal verge with more severe systemic symptoms
• Furuncle or carbuncle - S. aureus infection of hair follicles, but less common in sacrococcygeal region 1
• Hidradenitis suppurativa - chronic recurrent condition, usually involves apocrine gland-bearing areas
• Epidermoid cyst with secondary infection - can occur anywhere but less specific to natal cleft location
• Sacrococcygeal teratoma (rare in adults) - would present as a mass rather than acute inflammatory process

Immediate Management

Perform incision and drainage as the primary treatment. 1 This is indicated for all inflamed pilonidal cysts presenting as abscesses or large furuncles.

Procedural Approach:

• Make an incision over the fluctuant area to adequately drain purulent material 3
• Explore the cavity and remove any visible hair or debris 3
• Consider curettage of the cyst cavity, which has shown good results with lower morbidity and faster healing compared to formal excision 3
• Pack the wound loosely or leave open for healing by secondary intention 4

Antibiotic Therapy Decision

Base the decision to add antibiotics on the presence or absence of systemic inflammatory response syndrome (SIRS). 1

Antibiotics are NOT routinely needed if: 1

• Temperature is normal (not >38°C or <36°C)
• Heart rate <90 bpm
• Respiratory rate <24 breaths/minute
• White blood cell count normal (not >12,000 or <4,000 cells/µL)
• No surrounding cellulitis with purulent drainage

Antibiotics ARE indicated if: 1

• SIRS criteria present (fever, tachycardia, tachypnea, or abnormal WBC)
• Extensive surrounding cellulitis
• Immunocompromised patient
• Failed initial drainage

If antibiotics are needed, use an agent active against MRSA (such as trimethoprim-sulfamethoxazole or doxycycline) given the high prevalence of community-acquired MRSA in skin abscesses. 1

Post-Procedure Wound Care

Implement appropriate wound care immediately after drainage to prevent healing disturbances and reduce recurrence risk. 4

• Rinse wound daily with clean water or antimicrobial solution 4
• Apply appropriate dressings (sterile compress or absorbent dressing) 4
• Consider autolytic debridement if fibrin develops 4
• Expect healing time of approximately 4 weeks (range 3-12 weeks) for wounds healing by secondary intention 4, 5

Follow-Up and Recurrence Prevention

Evaluate for local predisposing factors, as recurrent abscesses at the same site should prompt investigation for pilonidal disease characteristics. 1

At follow-up visit (within 3 days): 1

• Reassess if no improvement within 3 days of drainage
• Ensure adequate drainage and wound healing progression
• Rule out complications (abscess, deeper infection)

For recurrence prevention: 1

• Hair removal from the natal cleft area (shaving or depilatory creams) to prevent hair penetration 6, 3
• Maintain good hygiene of the sacrococcygeal area 1
• Consider laser hair removal or intense pulsed light therapy for patients with hirsutism, which may provide longer disease-free intervals 6

Definitive Surgical Referral

Refer to general surgery for definitive treatment if: 5, 3

• Recurrent episodes despite conservative management
• Complex sinus tracts identified
• Patient desires definitive cure rather than repeated drainage procedures
• Chronic pilonidal disease with multiple openings

Surgical options include excision with primary closure, excision with open healing, or minimally invasive endoscopic techniques, with average surgical time of 40 minutes and healing in 4 weeks. 5

Key Pitfalls to Avoid

• Do not prescribe antibiotics routinely - they are unnecessary without SIRS or extensive cellulitis and contribute to resistance 1
• Do not perform formal excision acutely - incision and drainage is sufficient for acute presentation; definitive excision is reserved for recurrent or chronic disease 3
• Do not ignore hair as the causative factor - failure to address hair removal leads to high recurrence rates 3
• Do not delay drainage - prompt incision and drainage relieves pain and prevents progression 1