Emergency Department Care
Patients with pilonidal disease without abscess or other significant symptoms should be discharged from the ED with reassurance and instructions to return if signs of an abscess develop. Patients should maintain adequate hygiene of the area and closely observe for infection. Current literature review by this author failed to note an indication for surgical intervention at this stage. [14] However, if clinical signs of a pilonidal abscess are noted, primary incision and drainage should be performed in the ED for symptomatic relief, as follows [3, 15, 16] :
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Place the patient in the prone position as comfortably as possible and have them undress adequately to expose the region in question. Rarely, a patient may require a small amount of sedative to tolerate the procedure, though reassurance by medical personnel is usually adequate.
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Using sterile technique and instrumentation, prepare the region for incision with povidone-iodine (Betadine) or other suitable skin cleansing agent. Local anesthetic should be infiltrated generously with a small-gauge needle along the planned incision site (use of local vasoconstrictor such as epinephrine is acceptable).
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The primary incision is longitudinal and should be made off the midline into skin, subsequently carrying it down to the level of subcutaneous tissue to open up the abscess cavity. As much purulent drainage and debris should be removed from the site as possible; blunt dissection may assist with this process as the patient can tolerate.
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Once the space is evacuated adequately, ribbon wound packing should be placed to occupy the space and allow further passive drainage. The space should not be packed tightly, and there is no known advantage to using medicated ribbon gauze. Cover dressing can be with 4 X 4 gauze or an ABD pad secured with surgical tape. The patient may require brief amounts of nonopioid analgesia post procedure. [9]
Consultations
A surgical consultation is only needed if the diagnosis and management are unclear from the patient presentation. The presence of chronic disease with recurrent painful episodes may warrant surgical consultation for surgical excision of all sinus tracts. If there is a question of whether a true pilonidal abscess has formed, ultrasound can be used to identify the abscess prior to definitive incision and drainage. The practice of exploratory needle aspiration in these instances seems to have gone by the wayside.
Medical Care
The overall goal of nonoperative medical therapy is to remove hair and debris that may contribute to a chronic inflammatory state that keeps any potential skin tracts open. Shaving or laser epilation therapy may be used as an adjunctive therapy if an abscess is not present to remove hair from the gluteal cleft and surrounding skin. After hair removal, patients without abscess may also be treated with phenol or fibrin glue applied to the affected area to remove granulation tissue and prevent further formation of debris, which can assist with sinus closure. [17]
Surgical Care
Outside of standard incision and drainage, patients with chronic pilonidal disease may require excision with primary repair, excision and healing by seondary intention, or excision with marsupialization. The decision to place a drain is based on patient factors and surgeon preference. In the setting of complex, recurrent pilonidal disease, flap-based procedures may be performed if other techniques have not been successful. [17]
Prevention
Routine physical activity may be helpful for prevention, as a sedentary lifestyle is a risk factor for developing pilonidal disease.
Long-Term Monitoring
First, packing removal needs to be performed. Generally, a formal wound check should be offered to the patient in the ED or office in 1-2 days, with removal of the packing at that time and redressing of the wound. However, if the patient is reliable and unwilling to return to the ED, he or she can remove the packing at home as long as care is taken to ensure that the ribbon is completely intact when removed. Once packing is removed, site cleansing with warm shower water or sitz baths should begin right away and be taken 2-3 times per day. A clean dressing should be applied after cleansing and continued until the abscess cavity has closed primarily.
Surgical follow-up is recommended in about 1-2 weeks. This allows the surgeon to examine the wound for healing, assess for potential recurrence, ensure that no other diagnosis and therapy should be considered, and arrange for definitive care of the sacrococcygeal region if necessary. [5, 9] At least some literature suggests that conservative therapy with good local hygiene and site shaving every 1-3 weeks have been shown to be as effective in preventing recurrence as a secondary surgical procedure. [2]
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Pilonidal cyst.
