Treatment of Pilonidal Cyst
For acute pilonidal abscesses, perform immediate incision and drainage, which is the definitive treatment for all cutaneous abscesses including pilonidal disease. 1
Acute Pilonidal Abscess Management
Immediate Surgical Intervention
- Incision and drainage is the primary treatment for inflamed pilonidal cysts presenting as abscesses, allowing thorough evacuation of pus and probing of the cavity to break up loculations. 1, 2
- After drainage, manage the wound either by open healing (secondary intention) with dry dressing coverage, or by primary closure with suturing. 2
Antibiotic Indications
- Add antibiotics active against S. aureus only if the patient exhibits systemic inflammatory response syndrome (SIRS), defined as: 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. 1
- Use an antibiotic active against MRSA for patients with markedly impaired host defenses or those meeting SIRS criteria. 1
- For uncomplicated cases after incision and drainage, systemic antibiotics are generally unnecessary unless extensive surrounding cellulitis or systemic signs of infection are present. 2
Chronic and Recurrent Disease Management
Definitive Surgical Approach
- A recurrent abscess at a previous site mandates evaluation for pilonidal cyst as the underlying cause, as eradication of the pilonidal disease can be curative. 1
- Surgical excision of the cyst remains the most commonly used definitive procedure, though incision and curettage is preferred by many surgeons for superior outcomes regarding morbidity, healing, recurrence, and cure. 3
- Culture the drainage early in the course of recurrent infections to guide antibiotic selection. 2
Recurrence Prevention Protocol
- Implement a 5-day decolonization regimen for recurrent pilonidal abscesses, including:
- Twice-daily intranasal mupirocin
- Daily chlorhexidine washes
- Daily decontamination of personal items (towels, sheets, clothes) 1
- Consider a 5-10 day course of antibiotics active against the cultured pathogen for recurrent cases. 2
Post-Surgical Wound Care
Optimal Wound Management
- For wounds healing by secondary intention, implement appropriate mechanical or autolytic debridement, rinsing with antimicrobial solution, and adequate wound dressing as early as possible after surgery to avoid healing disturbances. 4
- Use of depilating cream for the border of the wound can help prevent recurrence. 5
Alternative Treatment Modalities
Laser Therapy for Recurrent Disease
- Nd-YAG laser hair removal (1064 nm wavelength) at 30-day intervals represents an effective alternative to repeat surgery for recurrent pilonidal cysts, with clinical disappearance typically achieved after 4-8 treatments and no disease recurrence in follow-up. 6
- This approach provides longer disease-free intervals and fewer recurrences compared to traditional surgical intervention, particularly beneficial for patients with hirsutism. 7, 6