Clinical Review

Treatment Options for Pilonidal Sinus

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References

Conservative Management Techniques

Phenol Injections
Liquid or crystallized phenol injections have been used for treatment of mild to moderate pilonidal cysts.13 Excess debris is removed by curettage, and phenol is administered through the existing orifices or pits without pressure. The phenol remains in the cavity for 1 to 3 minutes before aspiration. Remaining cyst contents are removed through tissue manipulation, and the sinus is washed with saline. Mean healing time is 20 days (range, +/14 days).13

Classically, phenol injections have a failure rate of 30% to 40%, especially with multiple sinuses and suppurative disease6; however, the success rate improves with limited disease (ie, no more than 1–3 sinus pits).3 With multiple treatment sessions, a recurrence rate as low as 2% over 25 months has been reported.14 Phenol injection also has been proposed as an adjuvant therapy to pit excision to minimize the need for extensive surgery.15

Simple Incision and Drainage
Simple incision and drainage has a crucial role in the treatment of acute pilonidal disease to decrease pain and relieve tension. Off-midline incisions have been recommended for because the resulting closures fared better against sheer forces applied by the gluteal muscles on the cleft.6 Therefore, the incision often is made off-midline from the gluteal cleft even when the cyst lies directly on the gluteal cleft.

Rates of healing vary widely after incision and drainage, ranging from 45% to 82%.6 Primary pilonidal cysts may respond well, particularly if the cavity is abraded; in one series, 79% (58/73) of patients did not have a recurrence at the average follow-up of 60 months.16

Excision and Unroofing
Techniques for excision and unroofing without primary closure include 2 variants: wide and limited. The wide technique consists of an inwardly slanted excision that is deepest in the center of the cavity. The inward sloping angle of the incision aids in healing because it allows granulation to progress evenly from the base of the wound upward. The depth of the incision should spare the fascia and leave as much fatty tissue as possible while still resecting the entire cavity and associated pits.6 Limited incision techniques aim to shorten the healing period by making smaller incisions into the sinuses, pits, and secondary tracts, and they are frequently supplemented with curettage.6 Noteworthy disadvantages include prolonged healing time, need for professional wound management, and extended medical observation.5 The average duration of wound healing in a study of 300 patients was 5.4 weeks (range, +/1.1 weeks),17 and the recurrence rate has ranged from 5% to 13%.18,19 Care must be taken to respond to numerous possible complications, including excessive exudation and granulation, superinfection, and walling off.6

Although the cost of treatment varies by hospital, location, and a patient’s insurance coverage, patient reports to the Pilonidal Support Alliance indicate that the cost of conservative management ranges from $500 to $2000.20

Excision and Primary Closure
An elliptical excision that includes some of the lateral margin is excised down to the level of the fascia. Adjacent lateral tracts may be excised by expanding the incision. To close the wound, edges are approximated with placement of deep and superficial sutures. Wound healing typically occurs faster than secondary granulation, as seen in one randomized controlled trial with a mean of 10 days for primary closure compared to 13 weeks for secondary intention.21 However, as with any surgical procedure, postoperative complications can delay wound healing.19 The recurrence rate after primary closure varies considerably, ranging from 10% to 38%.18,21-23 The average cost of an excision ranges from $3000 to $6000.20

A Cochrane review evaluated 26 studies comparing primary and secondary closure. This large analysis showed no clear benefit for open healing over surgical closure24; however, off-midline closure showed statistically significant benefit over midline closure (mean difference, 5.4 days; 95% CI, 2.3-8.5), and many experts now consider off-midline closure the standard of care in pilonidal sinus management (Figure 3).24,25

Figure3

Figure 3. Gross image of off-midline primary closure after excision of the defect.

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