Treatment of Pilonidal Cyst
Incision and drainage is the primary treatment for inflamed pilonidal cysts, with the wound typically managed by covering with a dry dressing and allowing healing by secondary intention. 1
Acute Management
Surgical Drainage
- Perform incision and drainage as the cornerstone of treatment, ensuring thorough evacuation of pus and probing the cavity to break up any loculations 1
- The surgical approach allows for complete drainage, which is essential for resolution of the acute infection 1
- After drainage, two wound management options exist: open wound healing (secondary intention) by covering with a dry dressing, or primary closure by suturing 1
- Avoid packing the wound with gauze, as this increases pain without improving healing outcomes 2
Antibiotic Use
- Systemic antibiotics are generally unnecessary after incision and drainage unless extensive surrounding cellulitis or systemic signs of infection are present 1
- Signs warranting antibiotics include: temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12,000 or <4,000 cells/µL 2
- For recurrent pilonidal abscesses, consider a 5-10 day course of antibiotics active against the cultured pathogen 1
Wound Care Following Drainage
Post-Surgical Management
- Simply covering the surgical site with a dry dressing is usually the easiest and most effective treatment 2
- For wounds healing by secondary intention, implement appropriate mechanical or autolytic debridement, rinsing with antimicrobial solution, and adequate wound dressing 3
- Complete wound closure can be expected within an average of 76 days with proper wound care 3
Ensuring Complete Drainage
- If infection persists or worsens, the cyst contents may not have been thoroughly evacuated 2
- Re-open the incision and ensure complete evacuation if drainage was inadequate, probing the cavity to break up any loculations or septations 2
Recurrent Disease Management
Definitive Treatment
- For recurrent abscesses at the same site, search for local causes and consider complete excision of the cyst and its wall once acute inflammation has resolved 2, 1
- Some surgeons prefer incision and curettage as an alternative to excision, citing favorable outcomes regarding morbidity, healing, recurrence, and cure 4
Important Considerations
- Always send excised tissue for histological examination, as malignant transformation, though rare (0.1% incidence), can occur in chronic pilonidal cysts 5, 6
- Chronic inflammation over many years can lead to squamous cell carcinoma, which requires en bloc resection with free margins 5, 6
Common Pitfalls to Avoid
- Do not close the wound without adequate drainage, as this leads to recurrent infection 2
- Avoid routine antibiotic prescription unless systemic infection signs are present 2, 1
- Do not skip histological examination of excised tissue, as this can miss malignant transformation 5
- Ensure complete evacuation during initial drainage to prevent persistent infection 2