Treatment of Pilonidal Cyst
Incision and drainage is the primary treatment for inflamed pilonidal cysts, with the decision between open healing versus primary closure depending on the degree of infection and complexity of the disease. 1
Acute Management: Surgical Drainage
For acute pilonidal abscesses, incision and drainage with curettage is superior to simple drainage alone, achieving faster healing (96% vs 78.7% complete healing) and significantly lower recurrence rates (11% vs 42%). 2
Surgical Technique Options:
- Incision and drainage with curettage: Thoroughly evacuate pus and probe the cavity to break up loculations, then curette the cavity walls 1, 2
- Simple incision and drainage alone: Associated with >40% recurrence rate and should be avoided when curettage is feasible 2
Wound Management Post-Drainage:
After surgical drainage, two approaches exist 1:
Open wound healing (secondary intention): Cover with dry dressing, allow healing from base upward
Primary closure: Suture the wound closed after drainage
Antibiotic Therapy
Systemic antibiotics are generally unnecessary after incision and drainage unless specific indications exist. 1
Indications for Antibiotics:
- Extensive surrounding cellulitis 1
- Systemic signs of infection (fever, sepsis) 1
- Recurrent pilonidal abscesses: Consider 5-10 day course targeting cultured pathogen 1
Common pitfall: Routine antibiotic prescription after uncomplicated drainage is unnecessary and should be avoided. 1
Chronic/Recurrent Disease Management
For recurrent disease at a previously infected site, search for and drain the pilonidal cyst early, obtaining cultures to guide antibiotic selection if needed. 1
Definitive Surgical Options for Chronic Disease:
Based on healing time, morbidity, and recurrence rates 4:
- Marsupialization: Lowest recurrence rate (4%) but requires specialized technique 4
- Excision with primary closure: 11% recurrence, fastest healing when successful 4
- Wide excision with open healing: 13% recurrence, reserved for grossly infected/complex cases only 4
The choice between excision with primary closure versus marsupialization should be the primary consideration for elective treatment of chronic pilonidal disease, as both offer superior outcomes compared to wide excision with secondary healing. 4
Post-Operative Wound Care
For wounds healing by secondary intention, implement early aggressive wound care to prevent healing disturbances 3:
- Appropriate mechanical or autolytic debridement
- Rinsing with antimicrobial solution
- Daily warm water sitting baths with douche 2
- Appropriate primary and secondary dressings 3
Most patients return to work 7-10 days after treatment regardless of technique. 2