Pilonidal treatment philosophy is undergoing a great change. In the past, the general assumption was that ALL tissue around the abscess needed to be excised. As you might imagine, this treatment philosophy lead to enormous wounds, some of which never healed. Today, you will find surgeons that advocate minimal treatment and surgeons who still that feel that all disease tissue must be removed. What will be presented on this page is a suggestion of treatments depending on severity of the disease. The choice is ultimately between you and your surgeon.
What should you do? Learn as much as you can about your body and Pilonidal abscesses. Stay calm. And think of medical knowledge as a jigsaw puzzle. Scientists know the outlines pretty well, but researchers are still struggling to make the smaller pieces fit into place. You need to learn everything you can about this disease, look at your symptoms, lifestyle and choices. Then discuss that with your doctor to come to an agreement on which direction treatment should take.
The consensus is that Pilonidals of this type should be left alone. Good hygiene and hair removal should be practiced diligently. Regular exfoliation of the cleft and use of No Bump Rx. Use a coccyx cushion to keep pressure off the area and use proper posture when sitting. Keep an awareness of the natal cleft and check regularly for any increase in discomfort or drainage. If a problem is developing, you want to nip it as soon as possible.
This is open for debate. Some doctors feel that an active Pilonidal should be treated with non-excision methods such as the Pit Picking, which involves removal of the midline pits and drainage of the abscess. Doctors who advocate the complete non-surgical approach will counsel to follow the approach listed above for No Symptoms. Again, keep an awareness of the natal cleft and check regularly for any increase in discomfort or drainage. If a problem is developing, you want to nip it as soon as possible.
An acute infection (needing to be lanced or antibiotics) is a red-flag of a growing problem. An abscess that is infecting regularly is one that is probably tunneling, and the longer treatment is delayed, the worse the problem may be getting. It is probably time to look at the Excision Treatments page if this describes you - Pit Picking is still a viable option at this point and should be considered if there is a surgeon near you that practices the procedure.
This is a problem that needs attention. It is still possible for Pit Picking and lancing as a first line treatment. If the more conservative approaches fail, your surgeon will almost certainly suggest excision surgery or Cleft Lift.
Your options now lean into full excision surgeries. The three that should be considered are excision with open healing, excision with closed healing and the Cleft Lift/Modified Karydakis flap. Failure of the more conservative methods usually indicates that there is a larger problem that needs more in-depth surgical exploration.
There are two important considerations here: the first is to differentiate between a recurrence of the abscess and a wound that will not heal. Wounds in the lower natal cleft don't get much oxygen and can be difficult to heal. If you are dealing with a non-healing wound, your first choice should be to look for a Wound Care Center (Wound Healing Center.) If it is determined that further surgery is needed, you might want to heavily consider a Cleft Lift or the Modified Karydakis flap. Both of these surgeries flatten the midline and raise up the depth of the natal cleft so that oxygen can get to the area.
It is important to remember that you have choices every step of the way. If your surgeon doesn't know some of these techniques, ask them to learn...or find one that does. Any surgeon who's mind is closed to new ideas, is not going to be a good partner in helping you rid yourself of this beast.
This page last updated: 11/03/2010