Around 26 out of 100,000 people in the U.S. are affected by pilonidal cysts, according to the National Library of Medicine. While this condition is not that common, it can cause significant complications.

Anyone in the wound care field will eventually encounter a patient with a pilonidal cyst. It may be a cyst or a treatment of an abscessed cyst or tract from a post-surgical wound. Here, we will learn a little more about this condition, including symptoms and challenges, that will help us better understand and treat it.

What is a pilonidal cyst?

Also called pilonidal sinus, the word “pilonidal” comes from Latin terms meaning “hair” and “nest.” Herbert Mayo, a British surgeon and physiologist originally described this condition in the 1830s.

For quite some time, pilonidal cysts were thought to be congenital — a condition stemming from specific fetal development. According to research from the National Library of Medicine, pilonidal disease is now considered an acquired condition. It is an infection under the skin, usually in the gluteal cleft.

The current thought concerning the development of the cyst is that hairs are forced into the skin by friction, and the body essentially responds with a foreign body reaction. Male patients are more likely to develop pilonidal sinuses than females. Other identified risk factors include obesity, a sedentary lifestyle, family history, tight clothing, a history of trauma to the tailbone, excessive body hair growth, and activities that cause friction, such as horseback riding and cycling.

Common pilonidal cyst symptoms

Cysts can be acute or chronic. An acute pilonidal cyst with an abscess is usually quite painful. Inflamed, swollen, and reddened skin may be present in the affected area. Drainage may be present. In more severe cases, complex sinuses may tract off the midline and create other openings.

This type of complex disease will usually be accompanied by foul smelling drainage and make it difficult for the patient to sit due to increased pain. Other signs of infection may be present, such as fatigue, nausea, and fever.

Chronic abscesses are usually due to cavities that have retained infection and create ongoing drainage. Also, watch for acute inflammation in some abscesses. Chronic cysts may occur when an acute cyst or abscess does not receive definitive treatment, such as an acute cyst treated only with antibiotics.

Diagnosing pilonidal cyst

To diagnose most pilonidal, complete a symptom history and physical examination. A radiographic image is unlikely to be necessary for diagnosis, although it may be useful in more severe cases to assist with treatment guidance.

Pilonidal cyst treatments and management

Soaking in a warm tub and over-the-counter pain medication may help lessen discomfort. Or apply a warm, moist compress to the affected area multiple times daily. Managing any drainage with absorbent dressings, such as abdominal (ABD) pads or gauze, may also be necessary. Although these actions may help manage the discomfort, treat any abscess to resolve the infection and prevent the risk of chronic cysts. If no abscess is present, some providers suggest conservative treatment of the cyst, which may include hair removal at the site of the cyst and good daily hygiene. Other non-surgical treatments have included the use of sclerosing agents and the use of fibrin, thrombin, and platelet-rich plasma.

Surgical approaches

A surgical procedure is usually necessary to adequately treat pilonidal cysts with abscesses. Several surgical treatment options are currently in use, although there is no primary, overall treatment choice. Pilonidal cysts and abscesses have often been treated by incision and drainage and allowed to heal by secondary intention. This allows the sinus to continue to drain, though it will require wound care and dressing changes within the home.

Wide excision is another treatment option. This would require the removal of a wedge of affected skin and subcutaneous tissue. Leaving this larger area open to healing by secondary intention creates a longer healing time and requires appropriate dressing changes. On the plus side, this type of treatment typically has a lower recurrence rate.

Use a technique called excision with marsupialization for multiple tracts with abscesses. This involves opening the midline and any secondary sinus tracts. The surgeon will suture tissue to the wound base in a way to decrease the likelihood of recurrence. This type of excision will also heal by secondary intention.

In some instances, a surgeon will choose to treat the cyst by excision with primary closure, using a variety of flap techniques (with varying recurrence rates) that a surgeon may choose for closure.

Consider newer treatment options that are being developed for this condition. These include video-assisted ablation and endoscopic treatment. These procedures aim to be minimally invasive, though they must prove a low recurrence rate.

Post-operative care and potential challenges

Post-operative care may include daily dressing changes in the hospital or in the home. At times, post-operative drains may be in place, requiring drain care education. Teach patients and caregivers to assess for signs of post-operative infection to report.

Pilonidal disease can be challenging for many reasons. One of the most difficult challenges is the disease’s history of recurrence. Some reports suggest recurrence can happen up to 20 years after the initial treatment.

Another challenge is the lack of community awareness about the condition. Patients are often unfamiliar with the disease and have a limited understanding of its pathophysiology, presentation, and treatment. This is evident as patients often wait to seek out medical care for a pilonidal cyst until faced with a life-limiting symptom, such as significant pain or a draining abscess.

This disease most often affects young adults, impacting their work and personal lives. Note if a patient expresses missing work or withdrawal from normal activities as this is common with acute disease. Educate patients with a history of pilonidal cysts on management, the risk of recurrence, and symptoms to report to their healthcare provider.

Pilonidal cysts present a significant challenge due to their tendency for recurrence. Effective management involves not only choosing an appropriate surgical treatment but also ensuring thorough post-operative care and patient education. By raising awareness and providing comprehensive information, clinicians can empower patients to seek timely intervention and adopt preventive measures to manage their condition.

Want to learn more about managing pilonidal cysts? Take WCEI's Skin and Wound Management course and elevate your expertise in wound care.

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Tara Call Triplett, RN, WCC, CHFN

Tara Call Triplett has over 20 years of experience as a registered nurse and is the founder of Call to Health Communications. She is nationally certified in both wound care and heart failure. Triplett currently leads an amazing team of clinicians at an award winning outpatient wound care clinic. She has a passion for teaching and mentoring the next generation of wound care clinicians.

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