Which Treatment is Right for Me?

There is a lot of debate about treatments for Pilonidal Disease.  Opinions run the gamut from no treatment to "flaps" for everyone.  You will find surgeons that advocate minimal treatment and surgeons 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 between you and your surgeon. 

What should you do? Learn as much as you can about your body and Pilonidal Cysts. 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.

No symptoms to mild discomfort once yearly or less frequently:
The consensus is that cysts 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. 

Mild discomfort several times a year:
This is open for debate.  Some doctors feel that an active cyst should be treated with non-excision methods such as the Bascom technique, which involves removal of the midline pits and drainage of the cyst. Doctors who advocate the complete non-surgical approach will counsel to follow the approach listed above for No Symptoms.

Acute infection several times a year:
An acute infection (needing to be lanced or antibiotics) is a red-flag of a growing problem.  The consensus from my reading is that these cases should be handled with non-excision methods first.  A cyst that is infecting regularly is one that is probably tunneling, and the longer treatment is delayed, the worse the problem may be getting. Look to the Bascom technique of removal of the midline pits and drainage.

Acute infection monthly or more often:
This too should be treated first with non-excision methods of removing the pits and drainage of the cyst.  The sinuses should be layed open and brushed to encourage healing. A cyst that is forming new sinus openings regularly is an aggressive cyst and it might be recommended in this case to move directly to excision surgery as soon as possible.

Failure of non-excision methods:
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/Karydakis flap. Failure of the more conservative methods usually indicates that there is possibly deeper abscess to be dealt with or the shape of the midline has an overhang that is creating problems.

Failure of excision surgery:
First, you 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 and/or the Karydakis flap. Both of these surgeries flatten the overhang in the midline that causes wound healing failure.

There are other flap surgeries, some of which dramatically change the shape of your buttocks and some will leave extensive scarring, thus we tend to not recommend those as highly.  I also have a belief that some severe cases that defy surgery are possibly misdiagnosed Hidradenitis Suppurativa, a disease with a very similar pattern to Pilonidal. 
 

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.

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