What are the treatment guidelines for a patient with a pilonidal sinus?

Treatment Guidelines for Pilonidal Sinus

For acute pilonidal abscess, perform incision and drainage as primary treatment, reserving antibiotics only for patients with systemic inflammatory response syndrome (SIRS); for chronic pilonidal sinus disease, surgical excision with marsupialization is the definitive treatment of choice with the lowest recurrence rate of 6.35%. 1

Acute Pilonidal Abscess Management

Primary Treatment

• Incision and drainage is the recommended first-line intervention for pilonidal abscesses, demonstrating low recurrence rates and effective disease control 1, 2
• This procedure can be performed in the outpatient setting, allowing patients to maintain near-normal work status 2

Antibiotic Indications

• Antibiotics should only be added if SIRS criteria are present, defined as: 1
  • Temperature >38°C or <36°C
  • Heart rate >90 bpm
  • Respiratory rate >24 breaths/min
  • WBC >12,000 or <4,000 cells/µL
• When antibiotics are indicated, select agents active against MRSA and streptococci 1
• Culture the abscess if recurrent disease is present to guide targeted antibiotic therapy 1

Chronic Pilonidal Sinus Disease

Definitive Surgical Management

• Surgical excision with marsupialization is the preferred approach, offering a recurrence rate of only 6.35% 1, 3
• Marsupialization demonstrates superior outcomes compared to primary closure, which has a recurrence rate of 57.8% 3
• Mean healing time with marsupialization is approximately 27 days, significantly faster than open excision (46 days) but longer than primary suture (12 days) 3

Alternative Surgical Approaches

• Open excision without closure is reserved for large, inflamed, or recurrent cases 3
• Primary closure techniques should be avoided due to high recurrence rates (57.8%) despite shorter initial healing times 3

Conservative Management Considerations

Non-Surgical Approach

• Conservative therapy includes meticulous hair control through natal cleft shaving, improved perineal hygiene, and limited lateral incision for abscess drainage 2
• This approach effectively controls disease in the outpatient setting with minimal work disruption 2
• However, conservative treatment has inferior long-term outcomes compared to surgical intervention, with cure rates of only 68.3% versus 100% for surgery at 2-year follow-up 4

Phenol Injection

• Low-concentration (40%) phenol solution can be considered as a minimally invasive option, with recurrence rates of 7.4% 5
• This causes less tissue destruction than 80% phenol (which has 15.5% recurrence) while maintaining therapeutic efficacy 5
• Final evaluation of phenol and other locally destructive treatments (pit picking, fistuloscopy, laser) is still pending 6

Recurrence Prevention Protocol

For Recurrent Disease

• Implement a 5-day decolonization regimen if S. aureus is cultured: 1
  • Twice-daily intranasal mupirocin
  • Daily chlorhexidine washes
  • Daily decontamination of towels, sheets, and clothes
• Administer a 5-10 day antibiotic course active against the isolated pathogen 1
• Culture recurrent abscesses early to guide antibiotic selection 1

Initial Assessment Requirements

Key Diagnostic Factors

• Search for associated pilonidal cysts or hidradenitis suppurativa as local predisposing factors 1
• Identify foreign material in the sinus tract, which contributes to disease persistence 1
• Document history of recurrent abscesses at the previous infection site 1

Common Pitfalls to Avoid

• Do not use primary closure techniques except in highly selected cases, as this leads to unacceptably high recurrence rates of nearly 60% 3
• Avoid routine antibiotic use for simple abscess drainage without SIRS criteria, as this provides no additional benefit 1
• Do not rely solely on conservative management for definitive treatment, as surgical intervention achieves significantly higher cure rates (100% vs 68.3%) 4