Treatment of Pilonidal Sinus Disease
For acute pilonidal abscess, perform incision and drainage without antibiotics unless systemic inflammatory response syndrome (SIRS) is present; for chronic pilonidal sinus, surgical excision with marsupialization is the definitive treatment of choice. 1
Acute Pilonidal Abscess Management
Incision and drainage is the primary treatment for pilonidal abscesses, which demonstrates low recurrence rates when performed appropriately. 1
When to Add Antibiotics
Antibiotics should only be prescribed if SIRS criteria are met, 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 Requirements
Obtain abscess cultures only if recurrent disease is present to guide targeted antibiotic therapy. 1 This prevents unnecessary broad-spectrum antimicrobial use and allows for pathogen-specific treatment in treatment failures.
Chronic Pilonidal Sinus Disease
Surgical excision with marsupialization is the preferred definitive approach, offering a recurrence rate of only 6.35%. 1 This represents the best balance of efficacy and outcomes among surgical options.
Alternative Surgical Approaches and Their Limitations
While multiple surgical techniques exist, they have significant drawbacks: 2
- Primary closure: Highest complication rate (31%) and recurrence rate (13.8%), with infection in 17.2% and wound dehiscence in 13.8% of cases 2
- Limberg flap: Longest hospitalization (3.61 days) with 15.8% complication rate 2
- Unroofing: Low complication rates but requires prolonged wound care 2
The marsupialization group experienced the longest return-to-work period (20.12 days), but this must be weighed against its superior recurrence profile. 2
Conservative Non-Excisional Management
For select patients who refuse surgery or have significant comorbidities, conservative management can be effective: 3
- Meticulous natal cleft shaving to control hair accumulation
- Enhanced perineal hygiene
- Limited lateral incision and drainage for abscess formation only
This approach demonstrated complete healing in 101 consecutive cases over 83 occupied-bed days, compared to 4,760 occupied-bed days for 240 operative procedures. 3 However, this requires strict patient compliance and is not definitive treatment.
Recurrence Prevention Protocol
For patients with recurrent pilonidal sinus where S. aureus is cultured, implement a 5-day decolonization regimen: 1
- Twice-daily intranasal mupirocin
- Daily chlorhexidine body washes
- Daily decontamination of towels, sheets, and clothing
Follow with a 5-10 day course of pathogen-specific antibiotics based on culture results. 1
Initial Assessment Priorities
When evaluating pilonidal sinus, specifically search for: 1
- Concurrent pilonidal cyst or hidradenitis suppurativa as local predisposing factors
- Foreign material within the sinus tract
- History of recurrent abscess at the same site
These factors significantly influence treatment planning and recurrence risk.
Critical Pitfalls to Avoid
Do not perform primary closure as the first-line surgical option—it carries the highest complication and recurrence rates among all surgical approaches. 2 The 31% complication rate and 13.8% recurrence rate make this an inferior choice despite its theoretical appeal of faster healing.
Avoid prescribing antibiotics for simple abscess without SIRS criteria, as this promotes resistance without improving outcomes. 1
Adjunctive Wound Management
For complex cases following excision, vacuum-assisted closure (wound-VAC) can facilitate healing, with granulation tissue formation typically occurring by postoperative day 8, followed by secondary intention healing over 3 weeks. 4 This is particularly useful for large defects or recurrent disease with extensive tissue involvement.