Treatment of Pilonidal Cyst
Incision and drainage is the primary treatment for an inflamed pilonidal cyst, with antibiotics reserved only for patients showing systemic signs of infection. 1, 2
Acute Pilonidal Abscess Management
Immediate incision and drainage should be performed for any inflamed pilonidal cyst presenting as an abscess, as this is the definitive treatment for all cutaneous abscesses including pilonidal disease. 3, 1 The procedure involves thorough evacuation of pus and probing of the cavity to break up any loculations. 2
When to Add Antibiotics
Antibiotics are generally unnecessary after incision and drainage unless specific criteria are met. 2 Add antibiotics directed against S. aureus only if the patient exhibits systemic inflammatory response syndrome (SIRS), defined as: 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
An antibiotic active against MRSA is specifically recommended for patients with markedly impaired host defenses or those meeting SIRS criteria. 3, 1
Wound Management After Drainage
After surgical drainage, simply covering the surgical site with a dry dressing is the easiest and most effective treatment. 3 The wound can heal by secondary intention (open healing) or be closed primarily with sutures. 2 One study found that packing the wound caused more pain without improving healing compared to just covering with sterile gauze. 3
Chronic and Recurrent Disease
A recurrent abscess at a previous site mandates evaluation for an underlying pilonidal cyst, as this represents a local predisposing factor that requires definitive surgical management for cure. 3, 1, 2 The presence of recurrent disease indicates the need for more definitive excisional surgery rather than simple drainage alone.
Surgical Options for Definitive Treatment
Multiple surgical approaches exist for chronic pilonidal disease, with varying healing times and recurrence rates: 4
- Excision with primary closure: Fastest complete healing but 14% wound infection rate and 11% recurrence
- Marsupialization: Lowest recurrence rate at 4%
- Wide excision with open healing: Should be reserved only for grossly infected and complex cysts, as healing is prolonged 4
Recurrence Prevention
For patients with recurrent pilonidal abscesses, implement a 5-day decolonization regimen including: 1
- Twice-daily intranasal mupirocin
- Daily chlorhexidine washes
- Daily decontamination of personal items (towels, sheets, clothes)
Common Pitfalls to Avoid
Do not perform Gram stain and culture routinely for uncomplicated pilonidal cysts, as this is not recommended for inflamed epidermoid cysts. 3 However, culture should be obtained if there is extensive surrounding cellulitis or the patient requires systemic antibiotics. 2
Avoid ultrasonographically guided needle aspiration, as this was successful in only 25% of cases overall in randomized trials and is not recommended. 3