Management of intergluteal pilonidal disease
- Daniel J Sullivan, MD, MPH
Daniel J Sullivan, MD, MPH
- Assistant Professor of Medicine
- Harvard Medical School
- David C Brooks, MD
David C Brooks, MD
- Associate Professor of Surgery
- Harvard Medical School
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
- Section Editors
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
Intergluteal pilonidal disease is an infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks (figure 1) . Management is variable and guided by the clinical presentation and extensiveness of disease [1-4]. The clinical manifestations and diagnosis are reviewed separately. (See "Intergluteal pilonidal disease: Clinical manifestations and diagnosis".)
An acute pilonidal abscess is managed with an incision and drainage (I&D) procedure at the time of presentation, usually under local anesthesia. This management approach is consistent with that described for a skin and subcutaneous abscess at other sites. (See "Cellulitis and skin abscess: Treatment".)
The incision is generally performed lateral to the midline or over the area of maximal fluctuance, and all visible hair within the sinus is debrided [1,3-5]. Wounds are packed with gauze, and healing occurs by secondary intention in the acute setting. The wound edges may also be marsupialized (oversewing them while incorporating the base of the wound) to prevent premature closure of the skin. Curettage of the pilonidal sinus and tract at time of I&D or excision of midline pores is not typically performed in the clinical setting of an acute infection . The approach to an I&D procedure is described separately. (See "Technique of incision and drainage for skin abscess".)
An I&D, however, is not the definitive procedure for pilonidal disease, as recurrence rates range from approximately 20 to 55 percent [4,6]. In a retrospective review of 73 consecutive patients with a first episode of acute pilonidal abscess treated by I&D, 42 (58 percent) healed primarily, with a median time to healing of five weeks; 9 of the 42 developed recurrence of pilonidal disease at a median follow-up of 60 months . The overall cure rate following I&D was 45 percent.
CHRONIC OR RECURRENT DISEASE
The definitive treatment of chronic or persistent pilonidal disease is a surgical excision of all sinus tracts . The surgical procedures range from simple excision with or without primary closure to complex flap reconstruction.
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- ACUTE ABSCESS
- CHRONIC OR RECURRENT DISEASE
- Surgical approaches
- - Excision
- - Wound closure
- Primary versus delayed closure
- Off-midline versus midline primary sutured closures
- Types of off-midline closures
- ASYMPTOMATIC INCIDENTAL SINUS
- ROLE OF ANTIBIOTICS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS