What is the initial management for a pilonidal cyst of the umbilicus?

Initial Management of Umbilical Pilonidal Cyst

For an acute inflamed umbilical pilonidal cyst presenting as an abscess, perform immediate incision and drainage, which is the definitive treatment for all cutaneous abscesses including pilonidal disease. 1

Acute Presentation Management

Immediate Surgical Intervention

• Incision and drainage is the primary treatment for any inflamed pilonidal cyst presenting as an abscess, regardless of location 1
• This applies to umbilical pilonidal cysts just as it does to the more common sacrococcygeal variant 2, 3

Antibiotic Therapy Indications

• Add antibiotics directed against Staphylococcus aureus 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 an antibiotic active against MRSA for patients with markedly impaired host defenses or those meeting SIRS criteria 1

Conservative Management for Non-Acute Cases

Conservative treatment should be the first-line approach for umbilical pilonidal sinus without acute abscess formation. 2

• In a series of 26 patients with umbilical pilonidal sinus, 25 were successfully treated conservatively 2
• Conservative measures include:
  • Improved personal hygiene 2
  • Regular cleaning of the umbilical area
  • Hair removal from the periumbilical region 2, 4

Key Predisposing Factors to Address

• Male sex, young age, excessive hairiness, deep navel configuration, and poor personal hygiene are the primary predisposing factors 2
• Hair is the causative agent that creates the pilonidal disease through an acquired mechanism 2, 3, 4

Recurrence Prevention Strategy

For recurrent umbilical pilonidal abscesses, implement a 5-day decolonization regimen: 1

• Twice-daily intranasal mupirocin application
• Daily chlorhexidine body washes
• Daily decontamination of personal items (towels, sheets, clothing)

When Surgery Becomes Necessary

Reserve definitive surgical excision for cases that fail conservative treatment or have recurrent abscesses. 2

• Surgery is indicated when conservative treatment fails after appropriate trial 2
• Umbilectomy (complete excision of the cyst and umbilicus) without reconstruction is the recommended surgical approach 2, 4
• Reconstruction of the umbilicus is not recommended due to high risk of recurrence 4

Important Diagnostic Consideration

• Always search carefully for hair within any infected umbilical lesion, as this confirms the diagnosis of pilonidal sinus 4
• Umbilical pilonidal sinus can be misdiagnosed as irreducible umbilical hernia, urachus cyst, or other umbilical pathologies 2, 5
• The presence of hair in the infected umbilical cyst is the diagnostic criterion 4

Post-Surgical Wound Care (If Surgery Required)

• Wounds healing by secondary intention require appropriate mechanical or autolytic debridement, antimicrobial rinsing, and adequate wound dressing 6
• Complete wound closure can be expected within an average of 76 days with proper wound care 6