Treatment Options for Pilonidal Sinus
Pilonidal sinus disease often presents as a chronic problem in otherwise healthy hirsute men. A range of conservative techniques to surgical flaps have been employed to treat this condition. We review the literature on management of pilonidal sinus disease, including conservative and surgical techniques as well as novel laser therapy. Given current evidence, off-midline repair is now considered the standard of care; however, no statistically significant difference has been noted between primary versus secondary closure or between the Karydakis flap and Limberg flap. Treatment should be tailored to the individual, taking into account recurrent disease, recovery time, and the surgeon’s comfort with the procedure.
Practice Points
- Mild pilonidal disease can be treated with conservative measures, including phenol injection and simple excision and drainage. Recurrent disease or the presence of extensive scarring or suppurative disease typically necessitates excision with flap closure.
- Off-midline procedures have been shown to be statistically superior to midline closure with regard to healing time, infection at the surgical site, and rate of recurrence.
- Laser excision holds promise as a primary or adjuvant treatment of pilonidal disease; however, large randomized controlled trials are needed to confirm early findings.
Laser Therapy
Lasers are emerging as primary and adjuvant treatment options for pilonidal sinuses. Depilation with alexandrite, diode, and Nd:YAG lasers has demonstrated the most consistent evidence.50-54 Th
Large randomized controlled trials are needed to fully determine the utility of laser therapy as a primary or adjuvant treatment in pilonidal disease; however, given that laser therapies address the core pathogenesis of pilonidal disease and generally are well tolerated, their use may be strongly considered.
Conclusion
With mild pilonidal disease, more conservative measures can be employed; however, in cases of recurrent or suppurative disease or extensive scarring, excision with flap closure typically is required. Although no single surgical procedure has been identified as superior, one review demonstrated that off-midline procedures are statistically superior to midline closure in healing time, surgical site infection, and recurrence rate.24 Novel techniques continue to emerge in the management of pilonidal disease, including laser therapy. This modality shows promise as either a primary or adjuvant treatment; however, large randomized controlled trials are needed to confirm early findings.
,Given that pilonidal disease most commonly occurs in the actively employed population, we recommend that dermatologic surgeons discuss treatment options with patients who have pilonidal disease, taking into consideration cost, length of hospital stay, and recovery time when deciding on a treatment course.
