Management of Pilonidal Cyst
For a young adult male with pilonidal cyst symptoms and family history, incision and drainage is the primary treatment for acute infection, followed by definitive surgical excision to prevent recurrence. 1
Acute Management
When infection is present (abscess formation), perform incision and drainage immediately. 1 This is the cornerstone of acute management for inflamed pilonidal cysts, similar to other cutaneous abscesses. The procedure should include:
- Thorough evacuation of pus 1
- Probing the cavity to break up loculations 1
- Culture of purulent material if systemic signs are present 1
Antibiotic Considerations
Antibiotics are NOT routinely required after incision and drainage unless systemic signs of infection are present. 1 Specifically, adjunctive antibiotics should be administered only when the patient exhibits:
- Temperature >38°C or <36°C 1
- Tachypnea >24 breaths per minute 1
- Tachycardia >90 beats per minute 1
- White blood cell count >12,000 or <4,000 cells/µL 1
If antibiotics are indicated, use an agent active against MRSA given the high prevalence of community-acquired MRSA in skin infections. 1
Definitive Surgical Management
After acute infection resolves, definitive surgical excision is recommended to prevent recurrence. 1, 2 The family history of pilonidal cysts suggests genetic predisposition, making recurrence more likely without definitive treatment.
Surgical Options
Two main approaches exist, each with distinct advantages:
- Excision with open wound healing (secondary intention): Lower recurrence rates but longer healing time (average 76 days) 3, 2
- Excision with primary closure: Faster initial healing but higher recurrence risk 2
- Incision and curettage: Some surgeons prefer this for lower morbidity and comparable cure rates 2
For patients with recurrent disease despite previous drainage procedures, excision with vacuum-assisted closure (wound-VAC) facilitates healing and reduces complications. 4
Post-Surgical Wound Care
Optimal post-surgical management includes appropriate wound debridement, antimicrobial rinsing, and adequate dressing changes. 3 Specific protocol:
- Rinse wound with antimicrobial solution 3
- Apply appropriate primary and secondary dressings 3
- For wounds healing by secondary intention, consider topical hemoglobin spray to promote granulation 3
- Use depilatory cream on wound borders to prevent hair accumulation 5
Prevention of Recurrence
A recurrent abscess at a previous pilonidal cyst site requires aggressive local management to eradicate the underlying cause. 1 Key preventive measures include:
- Regular hair removal from the sacrococcygeal area using depilatory creams 5
- Meticulous hygiene of the natal cleft 1
- Weight management if obesity is present 4
Common Pitfalls to Avoid
Do not treat pilonidal cysts with antibiotics alone without drainage—this will fail. 1 The primary pathology is a foreign body reaction to embedded hair, not a simple bacterial infection. 2
Do not confuse pilonidal cyst inflammation with cellulitis. 1 The term "cellulitis" is inappropriate for cutaneous inflammation associated with collections of pus. The correct terminology is "pilonidal cyst with surrounding inflammation," and treatment requires drainage, not just antibiotics. 1
Do not perform simple incision and drainage for recurrent disease without addressing the underlying sinus tracts. 4, 2 Recurrent cases require definitive excision of all sinus tracts and granulation tissue to achieve cure. 2