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

Treatment of Pilonidal Sinus

For acute pilonidal abscess, perform incision and drainage as the 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. 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
• Aspiration under local anesthetic using a wide-bore needle represents an alternative temporizing approach that allows 95% of patients to return to normal activities the following day, converting an emergency into an elective procedure 3
• The abscess cavity should be drained completely to dryness 3

Antibiotic Indications

• Antibiotics should NOT be routinely prescribed for simple abscess drainage 1
• Antibiotics are indicated ONLY when SIRS is present, defined by: 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 needed, select agents active against MRSA and streptococci, covering both anaerobes and aerobes 1, 3

Culture Requirements

• Obtain abscess culture if recurrent disease is present to guide targeted antibiotic therapy 1
• Send samples for microbiology when performing aspiration 3

Chronic Pilonidal Sinus Disease

Definitive Surgical Management

• Surgical excision with marsupialization is the preferred definitive approach, offering a recurrence rate of only 6.35% 1
• Off-midline repair techniques are now considered standard of care, as treatments that flatten the natal cleft reduce recurrence risk by 50% 4, 5
• En bloc excision with secondary healing should be abandoned in favor of primary asymmetric closure techniques 4
• Early excision of the pilonidal pit at the time of abscess treatment reduces the 40% risk of subsequent sinus formation 4

Timing of Elective Surgery

• Following aspiration and resolution of acute inflammation, plan elective excision and primary closure at a median of 9 weeks 3
• This staged approach allows complete resolution of inflammation in 95% of cases before definitive surgery 3

Conservative Management Strategy

Non-Operative Approach

• Conservative therapy can effectively control pilonidal sinus disease in selected patients through: 2
  • Meticulous hair control by natal cleft shaving
  • Improved perineal hygiene
  • Limited lateral incision and drainage for abscess only
• This approach promotes near-normal work status and demonstrates complete healing with significantly fewer occupied-bed days (83 days) compared to excisional procedures (4760 days over the same patient volume) 2

Hair Removal and Hygiene

• Laser hair depilation using long-pulsed alexandrite laser should be offered routinely to all patients following pilonidal sinus surgery to prevent recurrence 6
• A full course consists of three treatments at 6-week intervals, with top-up treatments as required (mean 3.9 treatments total) 6
• None of the patients receiving laser depilation developed recurrent disease at 1-year follow-up 6
• Patient education regarding meticulous personal hygiene is essential and often overlooked 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
• Prescribe a 5-10 day course of antibiotics active against the isolated pathogen 1

Predisposing Factors to Address

• Search for and treat pilonidal cyst or hidradenitis suppurativa as local predisposing factors 1
• Identify and remove foreign material in the sinus tract 1
• Drain and culture recurrent abscesses early to guide antibiotic selection 1

Critical Pitfalls to Avoid

• Do not routinely prescribe antibiotics for simple pilonidal abscess without SIRS criteria—this represents unnecessary antibiotic exposure 1
• Avoid en bloc excision with secondary healing, which has been superseded by superior techniques 4
• Do not neglect hair removal and hygiene counseling, as these are critical for preventing recurrence 6
• Ensure proper surgical training and supervision, as some techniques are operator-dependent and require expertise to achieve optimal results 4