Approach

The aims of treatment are to ameliorate symptoms, treat associated infection, and prevent recurrence.

Recurrence following conservative and surgical management is significant (33%), with the majority of recurrences (80%) occurring within the first year.[13]​ Conservative treatment (i.e., hair removal and perineal hygiene) may be utilised as primary treatment and/or adjunct treatment to reduce recurrence, although evidence is limited.[14]

Asymptomatic disease

Surgery is not recommended in patients who are asymptomatic, because the morbidity of the procedures outweighs the risk of the natural history of pilonidal disease.

Although data is limited in asymptomatic disease, conservative treatment with hair removal, improved perineal hygiene, weight loss, and avoiding prolonged sitting can be considered as it is low risk.[14]

Symptomatic disease with abscess

All acute pilonidal abscesses should undergo prompt incision and drainage. Depending on patient presentation and facility resources, it is ideal to debride all inflammatory debris and visible hair within an abscess cavity with unroofing and curettage.[14]​ In one randomised controlled trial comparing unroofing and curettage of the abscess with standard drainage, 96% of patients in the curettage group had complete wound healing within 10 weeks, compared with 79% of patients in the drainage group. Recurrence was also significantly less in patients treated with curettage instead of simple drainage (11% vs. 42%).[15]

​There is no conclusive evidence to support routine use of peri-procedural antibiotics, although expert opinion has suggested a role in patients with significant cellulitis after surgical drainage or those with underlying immunosuppression, high risk of endocarditis, methicillin-resistant Staphylococcus aureus (MRSA), or concurrent systemic illness.[16][17]​​​ If antibiotics are indicated, amoxicillin/clavulanate is sufficient coverage. If amoxicillin/clavulanate is contraindicated, a fluoroquinolone (e.g., ciprofloxacin) combined with metronidazole is adequate.

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[18]

  • Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

  • Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

Recurrence rates following drainage as high as 55% have been reported.[17]​ Following drainage, conservative strategies including perineal hygiene and cleft hair removal by either shaving, laser, or depilatory cream may be utilised to minimise recurrence rates. Of note, razor/cream depilation in the immediate postoperative rate has been associated with a higher recurrence rate. One systematic review on postoperative hair removal showed that postoperative laser epilation was associated with a lower recurrence rate (9%) than razor/cream depilation (23%) and no hair removal after surgery (20%).[19]

Symptomatic chronic or recurrent disease

Surgical therapy is the mainstay of treatment for pilonidal sinus and aims to remove all of the sinus tracts and skin pores (pits). Many surgical techniques have been described, but the optimal procedure is still controversial because of high recurrence rates and associated morbidity. Surgical options include excision with delayed wound closure, excision with midline primary closure, excision with primary off-midline closure (flap-based techniques), sinusectomy (aka trephination/Gips procedure), and endoscopic pilonidal sinus treatment.[4]​[14]​​

Excision with healing by secondary intention involves complete excision of sinus tracts and pits leaving the wound open to heal via granulation tissue formation from the base. The wound edges can be marsupialised to facilitate wound healing. The reported advantages of this procedure include lower recurrence and wound complication rates compared to midline closure, but comes at the cost of significant postoperative recovery, prolonged healing time, and low patient satisfaction.[4]

Excision with primary midline closure consists of complete excision of the sinus tracts and pits with subsequent closure of the wound edges at the natal cleft. Recurrence rates range from 4% to 45% with wound complications occurring in 14% to 74% of patients. The reported advantages of this procedure include faster healing compared to healing by secondary intention, however, it is associated with a high recurrence and wound complication rates.[4]​ For this reason, if a primary wound closure is preferred, an off-midline (lateral) closure is recommended.[20]

Excision with primary off-midline closure involves complete excision of the sinus tracts and pits via an incision lateral to the midline with subsequent advancement or rotational flap. These reconstructive options allow resection of greater amounts of diseased tissue with decreased tension across the wound to facilitate healing. The three most utilised techniques are the Karydakis flap, Bascom’s cleft-lift procedure, and the Rhomboid (Limberg) flap. Recurrence occurs in 0% to 6% of patients undergoing Karydakis flap, 0% to 11% of patients undergoing Bascom cleft-lift procedure, and 0% to 23% of patients undergoing Rhomboid flap. Wound complication rates range from 7% to 35% in patients undergoing a Karydakis flap, 11% to 40% in patients undergoing Bascom cleft-lift procedure, and 0% to 27% in patients undergoing Rhomboid flap. Time to healing and return to activities are generally similar among all three flap procedures. The advantages of off-midline primary closure are lower recurrence and wound complication rates, compared with midline closure, but are dependent on technical feasibility and surgeon experience.[4]​[20]​​

Sinusectomy (aka trephination/Gips procedure) consists of excision of sinus tract openings using skin trephines to remove all diseased tissue. Recurrence rates range from 0% to 33% with a wound complication rate of 4% to 6%. Time to healing and return to activities range from 20 to 92 days and 2 to 16 days, respectively. The advantages of this procedure are that it is less invasive with an easier postoperative recovery, has low wound complication rates, and lower recurrence rates compared to midline closure or healing by secondary intention. However, recurrence rates may be higher than the previously described flap procedures.[4]

Endoscopic pilonidal sinus treatment involves debridement of the pilonidal sinus under direct visualisation using a fistuloscope. Recurrence rates are low, wound complications are low, time to healing is moderate, and time to return to activities is quick. The advantages and disadvantages are similar to sinusectomy, with the additional disadvantage that it requires specialised equipment that is not readily available.[4]

In summary, the available literature suggests that surgical treatment should be tailored specifically to the patient, taking into consideration recurrence rates, wound complication rates, time to healing, and time to return to activities.

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