Is there any benefit to packing a pilonidal abscess?

No Benefit to Packing Pilonidal Abscess

Packing a pilonidal abscess after incision and drainage provides no proven benefit and should be avoided, as it increases pain and healthcare costs without improving healing time or reducing recurrence rates. 1, 2

Evidence Against Packing

The most recent guidelines explicitly state that wound packing after anorectal abscess drainage (which includes pilonidal abscesses) is:

• Costly and painful without providing clear benefits to the healing process 1
• Associated with increased pain during dressing changes and higher healthcare expenses due to prolonged use 1
• Not supported by evidence showing improvement in healing time, wound pain, fistula development, or abscess recurrence 1

The World Society of Emergency Surgery (WSES) 2021 guidelines make no recommendation regarding the use of packing after drainage of an anorectal abscess, based on the available literature—essentially acknowledging that despite common practice, the evidence does not support it 3

Alternative Management Approaches

Instead of traditional packing, consider:

• Placing a catheter or drain into the abscess cavity that drains into an external dressing, left in place until drainage stops 1, 2
• Simple incision and drainage without packing, which has been shown safe and effective in pediatric studies (though not pilonidal-specific) 4
• Warm water soaks or sitz baths starting 24-48 hours after drainage to promote healing 5

Definitive Treatment Options for Pilonidal Abscess

For pilonidal abscesses specifically, more definitive single-stage procedures may be superior to simple drainage:

• Marsupialization (drainage, curettage, and marsupialization) achieved 81.3% success with complete healing in 4-10 weeks in 95.3% of patients 6
• Aspiration followed by antibiotics (cefalexin and metronidazole for 7 days) was effective in 83% of selected patients with high satisfaction rates 7
• Loop diathermy excision allows one-stage definitive management of both acute abscess and chronic sinuses 8

Critical Pitfalls

• High recurrence rates (up to 44%) after simple drainage emphasize the need for complete and accurate initial drainage 1
• Risk factors for recurrence include inadequate drainage, loculations, horseshoe-type abscess, and delayed time from disease onset to incision 1
• One-third of perianal abscesses may develop a fistula-in-ano, increasing recurrence risk 1

Clinical Algorithm

1. Perform adequate incision and drainage without packing 1, 2
2. Consider definitive procedures (marsupialization, aspiration with antibiotics) in appropriate candidates rather than simple drainage alone 6, 7
3. Instruct patients to begin warm soaks 24-48 hours post-procedure 5
4. Reserve antibiotics only for patients with fever >38.5°C, diabetes, immunosuppression, or surrounding cellulitis 3, 5
5. Monitor for recurrence given the 14-44% recurrence rate 1, 6