Pilonidal Cyst: Treatment and Complications
Primary Treatment Approach
Incision and drainage is the definitive first-line treatment for inflamed pilonidal cysts, allowing thorough evacuation of pus and probing of the cavity to break up loculations 1, 2. This surgical approach remains the standard of care despite various alternative techniques being proposed over the years 3.
Acute Management Algorithm
For acute pilonidal abscesses:
- Perform immediate incision and drainage for all inflamed cysts presenting as abscesses 2
- Probe the cavity thoroughly during drainage to break up any loculations 1
- After drainage, choose between two wound management strategies:
Antibiotic Indications
Antibiotics are generally unnecessary after uncomplicated incision and drainage 1. However, specific situations require antimicrobial therapy:
- Add antibiotics active against S. aureus if the patient exhibits systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cell count >12,000 or <4,000 cells/µL 2
- Use MRSA-active antibiotics for patients with markedly impaired host defenses or those meeting SIRS criteria 2
- Consider a 5-10 day antibiotic course active against cultured pathogens for recurrent pilonidal abscesses 1
Post-Surgical Wound Care
For wounds healing by secondary intention, implement a comprehensive wound care regimen early to prevent healing disturbances 4:
- Perform appropriate mechanical or autolytic debridement 4
- Rinse with antimicrobial solution 4
- Apply topical haemoglobin 4
- Use appropriate primary and secondary dressings 4
This approach achieved complete wound closure within an average of 76 days in a case series, with excellent aesthetic outcomes in most patients 4.
Complications to Monitor
Recurrence
Recurrent abscess at a previous infection site mandates evaluation for underlying pilonidal disease as a local predisposing factor 2. The recurrence rate after surgical excision can reach 30% 5, making this the most significant complication.
For recurrent disease:
- Search for and drain the pilonidal cyst early in the course of infection 1
- Culture the drainage 1
- Consider definitive surgical excision, as eradication of underlying pilonidal disease can be curative 2
Wound Healing Disturbances
Postsurgical wound healing complications are frequently reported due to infection or other factors 4. Watch for:
- Development of fibrin coating on the wound 4
- Signs of infection requiring extended wound care 4
- Poor aesthetic outcomes with extensive cicatrization if healing disturbances are not addressed promptly 4
Abscess Formation
Development of abscess is associated with pain and discharge in previously asymptomatic lesions 6. This represents progression from chronic to acute disease requiring immediate drainage.
Recurrence Prevention Strategies
Implement a 5-day decolonization regimen for recurrent pilonidal abscesses 2:
- Twice-daily intranasal mupirocin application 2
- Daily chlorhexidine body washes 2
- Daily decontamination of personal items including towels, sheets, and clothes 2
Apply depilating cream to the wound border during healing 7 to reduce hair accumulation, which is the primary causative agent of pilonidal disease 3.
Alternative Treatment Considerations
Nd-YAG laser hair removal represents an emerging alternative to surgery 5. In a small series, 9 of 10 patients became asymptomatic after 2 treatments, with complete clinical resolution after 4-8 sessions and no recurrences during follow-up 5. This approach avoids the high postoperative pain and complications associated with traditional surgery 5.
Incision and curettage may offer advantages over complete excision 3 regarding morbidity, healing time, and recurrence rates, though excision remains the most commonly used surgical procedure 3.