Treatment of Pilonidal Cyst
For acute pilonidal abscesses, perform immediate incision and drainage, and for chronic or recurrent disease, definitive surgical excision is required to prevent recurrence. 1
Acute Pilonidal Abscess (First Presentation)
Immediate incision and drainage is the primary treatment for inflamed pilonidal cysts presenting as abscesses 1. This follows the standard approach for all cutaneous abscesses.
When to Add Antibiotics
Add antibiotics active against Staphylococcus aureus only if the patient exhibits systemic inflammatory response syndrome (SIRS) criteria 1:
- Temperature >38°C or <36°C
- Tachypnea >24 breaths/minute
- Tachycardia >90 beats/minute
- White blood cell count >12,000 or <4,000 cells/µL
Use MRSA-active antibiotics for patients with markedly impaired host defenses or those meeting SIRS criteria 1.
Chronic or Recurrent Pilonidal Disease
A recurrent abscess at a previous site mandates evaluation and definitive surgical management of the underlying pilonidal cyst, as eradication of the disease can be curative 1. Multiple surgical techniques exist, with excision being the most commonly used approach 2.
Surgical Options
- Excision with open or closed wound healing remains the most widely used method 2
- Incision and curettage is preferred by some surgeons for superior outcomes regarding morbidity, healing time, recurrence, and cure 2
- Endoscopic treatment using fistuloscopy demonstrates feasibility with mean healing time of 4 weeks, 7% complication rate, and 9% recurrence rate 3
Alternative Non-Surgical Approaches
Laser hair removal using Nd-YAG laser (1064 nm wavelength) represents an effective alternative to surgery for recurrent disease 4. Patients typically require 4-8 treatments at 30-day intervals, with clinical disappearance of cysts and no recurrence in follow-up 4. This avoids the high postoperative pain, adverse events, and 30% recurrence rate associated with traditional surgery 4.
Recurrence Prevention
Implement a 5-day decolonization regimen for recurrent pilonidal abscesses 1:
- Twice-daily intranasal mupirocin
- Daily chlorhexidine washes
- Daily decontamination of personal items (towels, sheets, clothes)
Post-Surgical Wound Management
For wounds healing by secondary intention after surgical intervention, implement comprehensive wound care early to avoid healing disturbances 5:
- Appropriate mechanical or autolytic debridement
- Rinsing with antimicrobial solution
- Topical hemoglobin application
- Appropriate primary and secondary dressings
This regimen achieves complete wound closure with excellent aesthetic outcomes when initiated promptly after surgery 5.
Common Pitfall
Do not delay definitive surgical evaluation for recurrent abscesses—repeated incision and drainage without addressing the underlying pilonidal disease leads to continued recurrence 1. The pilonidal cyst itself must be eradicated for cure.