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

Treatment of Pilonidal Abscess

Incision and drainage is the definitive treatment for pilonidal abscess and should be performed urgently—within 24 hours for stable patients, or emergently for those with sepsis, immunosuppression, diabetes, or diffuse cellulitis. 1, 2

Surgical Management

Timing and Approach

• Emergency drainage is mandatory for patients presenting with sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis 1
• For stable patients without these risk factors, surgical drainage should ideally occur within 24 hours 1, 2
• The procedure can be performed under local anesthesia in many cases, though operating room setting is preferred for optimal conditions 3

Surgical Technique Options

For acute pilonidal abscess, you have two evidence-based approaches:

1. Simple incision and drainage (initial management):

   • Provides immediate symptom relief and allows return to work within 7-10 days 4, 5
   • However, this approach carries a 40% recurrence rate and should not be considered definitive treatment 4, 6
   • Healing per primam occurs in only 58% of patients within 10 weeks 5
   • Actuarial cure rate plateaus at 76% after 18 months 5

2. Incision with curettage (superior approach):

   • This is the recommended technique for acute pilonidal abscess as it combines drainage with removal of the sinus tract 4
   • Achieves 96% healing within 10 weeks compared to 78.7% with simple drainage 4
   • Reduces recurrence to 11% versus 42% with drainage alone 4
   • All infected tissue and sinus tracts should be excised through an elliptical incision 6
   • The wound should be laid open with either marsupialization or beveling of skin edges to prevent premature closure 6

Critical Technical Points

• Keep the incision as close as possible to the anal verge to minimize potential fistula length while ensuring adequate drainage 1
• Complete drainage is essential—inadequate drainage is strongly associated with high recurrence rates 1
• For large abscesses, use multiple counter incisions rather than a single long incision to avoid step-off deformity and delayed healing 1

Antibiotic Therapy

Antibiotics are NOT routinely indicated after adequate surgical drainage. 1

Indications for Antibiotics

Consider antibiotics only in the following situations:

• Presence of sepsis or systemic infection 1
• Surrounding soft tissue infection or extensive cellulitis 1
• Immunocompromised patients 1
• Incomplete source control 1

Antibiotic Selection When Indicated

• Use empiric broad-spectrum coverage for gram-positive, gram-negative, and anaerobic bacteria, as these abscesses are frequently polymicrobial 1
• For patients requiring IV antibiotics: Piperacillin-tazobactam 3.375g IV every 6 hours provides comprehensive coverage 1
• Add MRSA coverage (vancomycin or linezolid) in recurrent cases, as MRSA prevalence can reach 35% in perirectal abscesses 1
• Duration: 5-10 days following operative drainage 1

Post-Operative Care

Wound Management

• Daily sitting in a warm tub with douche is recommended postoperatively 4
• The role of wound packing remains controversial—some evidence suggests it may be costly and painful without adding benefit 1
• Elevation of the affected area is recommended 7

Follow-Up

• Routine imaging after incision and drainage is not required 1
• Consider follow-up imaging only in cases of recurrence, suspected inflammatory bowel disease, or evidence of fistula or non-healing wound 1
• Weekly postoperative follow-up is strongly encouraged to assess progress and promote proper wound healing 6

Common Pitfalls to Avoid

• Do not perform primary closure in acute pilonidal abscess—this results in 14% recurrence at 12 months compared to secondary healing 8
• Do not consider simple incision and drainage as definitive treatment—patients should be counseled that definitive excision may be needed 4-8 weeks later if recurrence develops 6
• Do not delay drainage if a pilonidal abscess is clinically suspected, even if imaging is not immediately available 1
• Risk factors for recurrence include inadequate drainage, loculations (up to 44% recurrence), horseshoe-type abscess, and delayed time from disease onset to incision 1