Treatment for Pilonidal Cyst

In many with pilonidal disease, surgery is the cure.

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If your body has never gone to war with a pilonidal cyst, consider yourself lucky. The excruciating pain of pilonidal disease feels as if you were to press your tailbone up against the sharp corner of a table and hold it there.

Symptoms of pilonidal disease typically recur with ensuing infections becoming nastier and more painful. Moreover, in extreme cases where pilonidal cysts remain for prolonged periods of time, these nasty lesions have been known to track from the rear end all the way up to between the shoulder blades!

For most, the only panacea for the persistent pilonidal disease is surgery.

What is a pilonidal cyst?

Some debate exists as to not only how to best surgically treat a pilonidal cyst but also what causes it. A pilonidal cyst occurs at the level of the intergluteal cleft (butt crack) in the fleshy midline region overlying the sacrum and coccyx. Although women get them, too, pilonidal cysts typically affect young men after puberty.

Here's how a pilonidal cyst forms. First, impacted or ingrown hair follicles—possibly along with debris—break the skin and are enclosed in a cyst. Second, this cyst becomes infected forming a pilonidal abscess or boil replete with foul-smelling pus which drains through one or more pilonidal sinuses. Third, over time, infections recur and sinus tracts track proximally or upwards along your lower back.

A few potential risk factors have been identified for pilonidal disease:

  • hairiness
  • sitting for long periods of time
  • friction
  • obesity
  • tight clothing
  • poor hygiene (please note that many people who get these cysts wash regularly)
  • sacral dimple

During WWII, so many young GIs driving Jeeps developed a pilonidal disease that it was called "Jeep seat" or "Jeep riders' disease."

In addition to excruciating pain, tenderness, swelling and foul drainage of pus, the pilonidal disease can also raise white blood cell levels and cause fever.

Of note, depending on the drainage pattern, a pilonidal cyst is sometimes confused with a perirectal abscess, an altogether different condition.

Treatment of a pilonidal cyst

Because pilonidal cysts are lesions that often need surgery, antibiotics do little to help the condition unless there's also concomitant or comorbid cellulitis.

Initially, pilonidal abscesses are incised and drained by a physician using local anesthesia in either a primary care or emergency room setting. However, this intervention is usually a temporary fix with the irritation of the pilonidal cyst and associated sinus becoming a recurrent issue and nidus for further infection. Often, pilonidal cysts are much more invasive than they originally appear, and, besides surgery, their true depth is evident only by using ultrasound.

With the recurrence of pilonidal disease, pilonidal cysts are best treated by a surgeon in an operating room under intravenous sedation or general anesthesia. Although various surgical approaches have been suggested, I'll present two.

The first approach involves splitting open (unroofing) the sinus or tract, cutting open the cyst and scraping out (curretting) the base, and suturing the edges (marsupializing). The resultant wound is left open and can freely drain. If you choose or are offered this option, then it's important to keep the wound clear of hair and debris and meet for weekly wound care until healing is complete.

The second option involves complete excision of the cyst and sinus followed by placement of a suction drain before closure of the wound. With more extensive disease, resection is more extensive, too, and skin flaps may need to be created in order to close the wound. Such options require some follow-up, too. 

If you or a loved one suffer from the recurrent pilonidal disease, it's best to have surgery done by a surgeon in the operating room. Simply draining an abscess results in only temporary relief. As long as the pilonidal cyst remains intact, expect recurrent infection, pain, drainage of copious pus, and tracking. Even with surgery, pilonidal cysts sometimes recur, however, for many people surgery is curative.

Selected Sources

Bullard Dunn KM, Rothenberger DA. Colon, Rectum, and Anus. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014. Accessed March 10, 2015.

Burgess BE. Chapter 88. Anorectal Disorders. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. Accessed March 10, 2015

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