Treatment of Pilonidal Cyst
Surgical excision is the definitive treatment for pilonidal cysts, with the choice between excision with primary closure or marsupialization offering the best balance of healing time, morbidity, and recurrence rates for most patients. 1
Initial Management Approach
For acute presentations with abscess formation, immediate incision and drainage is required, either surgically or if spontaneous rupture occurs. 2 However, definitive surgical treatment should be planned after acute infection resolves.
Surgical Treatment Options
Excision with Primary Closure
- This approach provides the fastest complete healing time despite a 14% postoperative wound infection rate 1
- Recurrence rate of approximately 11% 1
- Patients typically return to daily activities within 5 days 2
- Average healing time ranges from 2-5 weeks for less extensive excisions 2
- Hospital discharge typically occurs within 1.14 days 2
Marsupialization
- Offers the lowest recurrence rate at 4% 1
- Represents an excellent alternative when considering long-term outcomes 1
- Healing times are comparable to primary closure 1
- Should be strongly considered for patients with prior recurrences
Wide Excision with Open Healing (Secondary Intention)
- Should be reserved only for grossly infected and complex cysts 1
- Results in significantly longer healing times (4-21 weeks reported) 2
- Failure to heal occurs in approximately 13.63% of cases 2
- Higher morbidity compared to other approaches 1
Minimally Invasive Endoscopic Treatment
- Emerging option with mean healing time of 4 weeks (3-12 weeks) 3
- Surgical complications in 7% and recurrence in 9% of cases 3
- Average surgical time of 40 minutes 3
- May be considered in specialized centers with appropriate equipment and expertise 3
Incision and Curettage
- Some surgeons advocate this as optimal regarding morbidity, healing, recurrence, and cure 4
- Less extensive than complete excision 4
- May be appropriate for selected cases without extensive disease 4
Postoperative Wound Management
Adequate wound care is critical to prevent healing disturbances, particularly for wounds healing by secondary intention. 5
The recommended regimen includes:
- Appropriate mechanical or autolytic debridement as needed 5
- Rinsing with antimicrobial solution 5
- Application of topical hemoglobin spray 5
- Appropriate primary and secondary dressings 5
- Early initiation of this protocol post-surgery to avoid healing disturbances 5
With proper wound care, complete closure can be achieved within an average of 76 days for secondary intention healing, with most wounds closing within 23-98 days. 5
Key Clinical Pitfalls
Avoid performing wide excision with secondary healing as routine treatment - this should only be used for grossly infected or complex cases, as it significantly increases healing time and morbidity without reducing recurrence rates. 1
Do not neglect structured postoperative wound care - healing disturbances are common when adequate wound management protocols are not followed, particularly for open wounds. 5
Recurrence is not correlated with postoperative infection or prior surgery 1, so the choice of surgical technique should be based on disease complexity and patient factors rather than infection history alone.
Treatment Algorithm
Acute abscess: Incision and drainage, followed by definitive surgery after resolution 2
Uncomplicated chronic pilonidal cyst: Excision with primary closure OR marsupialization 1
Grossly infected or complex cysts: Wide excision with open healing 1
Recurrent disease: Consider marsupialization (lowest recurrence rate at 4%) 1
Selected cases in specialized centers: Endoscopic treatment 3