From the Guidelines
Pilonidal cysts should be managed with a combination of good hygiene, removal of hair in the area, and avoidance of prolonged sitting, with antibiotics and surgical intervention reserved for infected or recurrent cases, as recommended by the Infectious Diseases Society of America 1. When managing pilonidal cysts, it is essential to consider the severity of the condition and the presence of any local causes, such as foreign material or hidradenitis suppurativa.
- Mild cases can be managed through warm sitz baths 2-3 times daily for 10-15 minutes, keeping the area clean and dry, and over-the-counter pain relievers like acetaminophen or ibuprofen (400-600mg every 6 hours as needed).
- For infected cysts, prompt evaluation by a healthcare provider is necessary, as antibiotics like clindamycin or trimethoprim-sulfamethoxazole may be needed for 7-10 days, as suggested by the practice guidelines for the diagnosis and management of skin and soft tissue infections 1.
- Recurrent or severe cases require surgical intervention, including incision and drainage for acute infections or more definitive procedures like excision with primary closure or flap techniques for chronic cases. To prevent recurrence, it is crucial to maintain good hygiene, remove hair in the area through shaving or laser hair removal, avoid prolonged sitting, and wear loose-fitting clothing, as these measures can help reduce the risk of pilonidal disease, which occurs when hair penetrates the skin in the gluteal cleft, creating an inflammatory reaction that can lead to abscess formation, particularly in young adults with sedentary lifestyles or occupations requiring prolonged sitting 1.
From the Research
Definition and Treatment of Pilonidal Sinus
- Pilonidal sinus is a disease characterized by recurrences that can become chronic and are often exacerbated by abscess formation 2.
- The treatment of pilonidal sinus is not standardized, and the choice of surgical approach depends on the clinical presentation and grade of the disease 2.
Surgical Techniques for Pilonidal Sinus
- Minimally invasive surgical approaches have been shown to be effective in treating pilonidal sinus, with a recurrence rate of 12.5% in a study of 5338 cases 2.
- Excision with primary closure and excision with flap reconstruction are also used to treat pilonidal sinus, with flap reconstruction showing superior results in terms of wound infection and recurrence rates 3.
- The use of a drain for antiseptic wound flushing has been shown to promote uneventful healing and prevent recurrences in patients treated with excision and primary closure 4.
Management of Acute Pilonidal Abscess
- Aspiration and antibiotic management of pilonidal abscess can be effective in preventing the need for emergent surgery and allowing for subsequent elective surgery 5.
- A study of 40 patients with acute pilonidal abscess found that 95% of patients responded to aspiration and antibiotic treatment, with complete resolution of acute inflammation and return to normal activities within a median of 5 days 5.
Recommendations for Treatment
- Minimally invasive techniques are suitable for small lesions that have not been previously surgically treated, but are associated with a higher recurrence rate than excisional methods 6.
- Off-midline techniques, such as the Karydakis procedure and the Limberg procedure, are preferred for patients who have undergone previous surgery and for those with large lesions, as they result in shorter wound healing times 6.
- Excision with midline suturing and postoperative permanent shaving are not recommended due to high recurrence rates and lack of evidence supporting their effectiveness 6.