What are the treatment options for a patient with a pilonidal cyst?

Treatment of Pilonidal Cysts

Incision and drainage is the primary treatment for inflamed pilonidal cysts, and systemic antibiotics are generally unnecessary unless there is extensive cellulitis or systemic signs of infection. 1, 2

Acute Pilonidal Abscess Management

Initial Surgical Intervention

• Perform immediate incision and drainage for all inflamed pilonidal cysts presenting as abscesses, ensuring thorough evacuation of pus and probing of the cavity to break up loculations 1, 2
• After drainage, manage the wound by either:
  • Open wound healing (secondary intention): Cover the surgical site with a dry dressing 1
  • Closed wound healing (primary closure): Suture the wound closed 1

Antibiotic Indications

• Antibiotics are NOT routinely needed after uncomplicated incision and drainage 1
• Add antibiotics directed against S. aureus only if the patient exhibits systemic inflammatory response syndrome (SIRS): 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 2
• Use MRSA-active antibiotics for patients with markedly impaired host defenses or those meeting SIRS criteria 2
• For recurrent pilonidal abscesses with extensive cellulitis, consider a 5-10 day course of antibiotics active against the cultured pathogen 1

Recurrent/Chronic Pilonidal Disease

Evaluation and Definitive Management

• Search for pilonidal cyst as the underlying cause in any recurrent abscess at a previous infection site, as eradication of the underlying pilonidal disease can be curative 1, 2
• Drain and culture early in the course of recurrent infection 1

Recurrence Prevention Strategies

• Implement a 5-day decolonization regimen for recurrent pilonidal abscesses, including:
  • Twice-daily intranasal mupirocin 2
  • Daily chlorhexidine washes 2
  • Daily decontamination of personal items (towels, sheets, clothes) 2

Post-Surgical Wound Care

For wounds healing by secondary intention after surgical intervention:

• Apply appropriate mechanical or autolytic debridement as needed 3
• Rinse with antimicrobial solution 3
• Use adequate wound dressing (dry-to-dry gauze or specialized dressings) 3, 4
• Wound-VAC therapy may facilitate healing in complex cases, with granulation tissue formation typically occurring within 8 days 4

Common Pitfall to Avoid

The most critical error is prescribing antibiotics routinely after simple incision and drainage—this is unnecessary and contributes to antibiotic resistance. Reserve antibiotics strictly for patients with extensive cellulitis or systemic signs of infection 1, 2.