Treatment of Pilonidal Cyst in a 26-Year-Old Female
Incision and drainage is the recommended initial treatment for an inflamed pilonidal cyst, with consideration for definitive surgical excision if recurrent. 1
Initial Management Approach
Acute Presentation (Inflamed/Infected Cyst)
- Perform incision and drainage as the primary intervention for acute pilonidal abscesses or inflamed cysts, which provides immediate symptom relief and allows for drainage of purulent material 1
- Culture the drainage fluid to guide antibiotic selection if systemic signs of infection are present 1
- Administer antibiotics active against S. aureus only if systemic inflammatory response syndrome (SIRS) is present, defined as temperature >38°C or <36°C, tachycardia >90 bpm, tachypnea >24 breaths/min, or WBC >12,000 or <4,000 cells/µL 1
- Consider MRSA-active antibiotics (such as vancomycin) if the patient has markedly impaired host defenses or meets SIRS criteria 1
Post-Drainage Wound Care
- Implement appropriate wound care regimen including mechanical or autolytic debridement, antimicrobial rinsing solution, and appropriate dressing changes 2
- Instruct the patient to rinse the wound with clean water and apply sterile dressings during the healing phase 2
- Expect healing by secondary intention to take approximately 76 days on average (range 23-98 days in most cases) with proper wound care 2
Definitive Surgical Management
Indications for Excision
- Recurrent pilonidal cysts at the same site warrant definitive surgical excision to address the underlying sinus tract and prevent further recurrences 1
- Chronic pilonidal disease with persistent sinus tracts despite previous incision and drainage procedures requires excision 3
Surgical Options
- Excision with healing by secondary intention is a widely accepted approach that balances morbidity, healing time, and recurrence rates 4
- Incision and curettage may be considered as an alternative with favorable outcomes regarding morbidity, healing, recurrence, and cure 4
- For complex cases with large defects, vacuum-assisted closure (wound-VAC) can facilitate granulation tissue formation and accelerate healing, typically requiring 8 days until fresh granulations form 3
Adjunctive Measures for Recurrence Prevention
Hair Removal Strategies
- Consider laser hair removal or intense pulsed light (IPL) therapy for patients with hirsutism to reduce recurrence risk, as hair is the primary causative agent 4, 5
- Laser/IPL treatments have demonstrated disease-free intervals of 7-36+ months in case series, potentially offering longer remission than traditional surgery alone 5
Decolonization Protocol (If Recurrent S. aureus Infection)
- Implement a 5-day decolonization regimen including twice-daily intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items (towels, sheets, clothes) 1
- This protocol should be considered specifically for recurrent S. aureus-associated infections, though efficacy data in the MRSA era are limited 1
Common Pitfalls to Avoid
- Do not routinely prescribe antibiotics for simple pilonidal abscesses without systemic signs of infection, as incision and drainage alone is typically sufficient 1
- Avoid primary closure in acute infected cases, as this increases risk of recurrence and wound complications 4
- Do not neglect proper wound care post-operatively, as inadequate wound management is a frequent cause of healing disturbances and poor aesthetic outcomes 2
- Recognize that pilonidal disease is acquired (not congenital) and caused by hair penetration, so addressing the hair component is essential for long-term success 4