What is the recommended treatment for a recurrent non‑draining pilonidal cyst in the intergluteal cleft?

Treatment of Recurrent Non-Draining Pilonidal Cyst

For a recurrent non-draining pilonidal cyst in the intergluteal cleft, surgical excision is the definitive treatment, with the choice between open healing (secondary intention) or primary closure depending on recurrence risk and patient factors. 1

Initial Management Approach

When the Cyst is NOT Currently Inflamed or Infected

Since you describe a "non-draining" cyst that keeps returning, this represents chronic pilonidal disease requiring elective surgical intervention rather than emergency drainage. 1, 2

Elective surgery is indicated to:

• Treat bothersome symptoms
• Prevent future abscess formation
• Address the underlying pathology (granuloma organized around embedded hairs with partially epithelialized sinus tracts) 2

Surgical Options

Primary Recommendation: Surgical Excision

The two main approaches after excision are: 1

1. Open wound healing (secondary intention) - Most commonly performed option

   • Wound is left open and covered with dry dressing
   • Longer healing time (average 76 days in case series) 3
   • Lower risk of infectious complications
   • At least 10% risk of failure or recurrence 2

2. Primary closure - Alternative approach

   • Wound is sutured closed after excision
   • Critical: Avoid midline closure - use paramedian or flap closure techniques instead 2
   • Reduces healing time and convalescence period
   • Higher risk of infectious complications compared to open healing 1, 2

Alternative: Minimally Invasive Techniques

For recurrent cases or patients wanting to avoid complex wound care: 2

• Combine foreign body extraction with mechanical debridement
• May include thermal or chemical cautery of granulomatous walls
• Equivalent recurrence rates to excision techniques
• Avoid difficult wound healing situations
• Particularly useful after failed radical excision

Critical Risk Factor Assessment

Before any surgical intervention, address modifiable risk factors: 2

• Active smoking - Single most important risk factor for complications and recurrence
  • Must achieve smoking cessation before elective surgery
• Obesity/excess weight
• Sedentary lifestyle
• Poor local hygiene

Antibiotic Use

Antibiotics are NOT routinely needed for non-inflamed pilonidal cysts undergoing elective excision unless: 1

• Extensive surrounding cellulitis is present
• Systemic signs of infection develop
• For recurrent abscesses, consider 5-10 day course based on culture results

Post-Surgical Wound Care for Open Healing

If secondary intention healing is chosen: 3

• Appropriate mechanical or autolytic debridement
• Rinsing with antimicrobial solution
• Sterile dressing changes
• Early initiation of proper wound care prevents healing disturbances

When to Consider More Aggressive Intervention

Red flags requiring immediate attention: 4

• Long-standing chronic cyst (>10-20 years)
• Change in appearance (verrucous, wart-like growth)
• Rapid growth
• These may indicate malignant transformation to squamous cell carcinoma (rare but serious complication)

Recurrence Management

If the cyst recurs after initial surgery: 2

• Comprehensive patient optimization (smoking cessation, weight management, activity level)
• Consider minimally invasive treatments (particularly laser therapy)
• May require repeat operation with different technique
• Recurrence rates remain approximately 10% even with optimal treatment 2

The key pitfall to avoid: Do not perform midline primary closure if choosing the closure approach - this significantly increases complications. 2