What is the best treatment approach for a patient presenting with a pilonidal sinus?

Treatment of Pilonidal Sinus

For acute pilonidal abscess, perform incision and drainage without routine antibiotics; for chronic pilonidal sinus disease, surgical excision with marsupialization is the definitive treatment, while conservative management with hair removal and hygiene can be effective in motivated patients who wish to avoid surgery. 1

Initial Assessment

When evaluating a patient with pilonidal sinus, determine whether the presentation is acute (abscess) or chronic (sinus tract disease):

• Search for predisposing factors including the presence of pilonidal cysts, hidradenitis suppurativa, foreign material in the tract, and history of recurrent abscesses at the same site 1
• Culture the abscess if recurrent disease is present to guide antibiotic selection 1

Treatment Algorithm Based on Presentation

Acute Pilonidal Abscess

Incision and drainage is the primary treatment with low recurrence rates 1

Antibiotic therapy should be reserved for specific indications:

• Only prescribe antibiotics if systemic inflammatory response syndrome (SIRS) is present: temperature >38°C or <36°C, heart rate >90 bpm, respiratory rate >24 breaths/min, or WBC >12,000 or <4,000 cells/µL 1
• When SIRS is present, use antibiotics active against MRSA and streptococci 1
• Early excision of the pilonidal pit at the time of abscess drainage reduces the 40% risk of subsequent sinus formation 2

Chronic Pilonidal Sinus Disease

You have two evidence-based options:

Option 1: Surgical Excision with Marsupialization (Preferred for Definitive Management)

• Offers the lowest recurrence rate of 6.35% and is the preferred approach for definitive management 1
• Treatments that flatten the natal cleft (like marsupialization) halve the recurrence risk 2
• En bloc excision with secondary healing should be abandoned in favor of primary asymmetric closure techniques 2

Option 2: Conservative Non-Excisional Management

• Effective in motivated patients who can maintain meticulous hair control through natal cleft shaving, improved perineal hygiene, and limited lateral incision/drainage for any abscess 3
• In one study, complete healing occurred over 83 occupied-bed days in 101 consecutive cases versus 4,760 occupied-bed days in 229 patients undergoing operative procedures 3
• Promotes near-normal work status and is preferred over excision in patients who can comply with the regimen 3

Risk Stratification for Surgical Candidates

Identify high-risk patients before surgery:

• Smoking is an independent risk factor for wound infection (p=0.027) and should prompt preoperative cessation 4
• Obesity (BMI ≥35) significantly increases infection risk (p=0.047), and active preoperative weight loss or simple laid-open procedure is recommended in obese patients 4
• Comorbidities including chronic infective skin conditions and immunomodulating drugs significantly affect healing time (HR 0.40,95% CI: 0.17-0.93; p=0.033) 5

Recurrence Prevention

For patients with recurrent pilonidal sinus and positive S. aureus culture:

• Implement a 5-day decolonization regimen: twice-daily intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of towels, sheets, and clothes 1
• Treat with a 5-10 day course of antibiotic active against the isolated pathogen 1

Postoperative Wound Management

For wounds healing by secondary intention:

• Negative pressure wound therapy (NPWT) achieves median healing time of 8 weeks versus 10 weeks with alginate/gauze dressings, though this difference is not statistically significant 5
• NPWT shows a trend toward lower recurrence (3.1% vs 12.5%) compared to daily dressings, though not statistically significant 5

Common Pitfalls to Avoid

• Do not routinely prescribe antibiotics for simple abscess drainage without SIRS criteria 1
• Avoid en bloc excision with secondary healing as it has been abandoned in favor of techniques with better outcomes 2
• Do not proceed with elective surgery in smokers or obese patients without addressing these modifiable risk factors first 4
• Ensure adequate follow-up beyond 3 years as recurrence rates must be assessed long-term 2