Which Pilonidal Treatment Is Right for You?
Pilonidal treatment philosophy has undergone a great change in the past twenty years. 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 and left patients with destroyed lives. That treatment philosophy came from a failure to understand that Pits in the buttock midline are what cause Pilonidal, not diseased tissue. Abscesses would recur again and again because surgeons were not removing the Pits that were actually causing the abscess, they were simply scooping out perfectly healthy tissue unnecessarily.
Today, you will find more and more surgeons that advocate minimal treatment and fewer surgeons who still adamantly that feel that all tissue around an abscess 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. Science has told us a lot about disease and how the body works but each and every body is unique. Your body is different, your immune system is different, your Pilonidal is uniquely your own. You need to learn everything you can about this disease, look at your symptoms, consider your lifestyle, and evaluate your options.
Some of you are going to be ultra conservative and take only the minimal steps as you think necessary. Some of you are going to be on the phone booking a surgery date within the next hour because you want this handled..yesterday. You know what is right for you, then discuss that with your doctor to come to an agreement on which direction treatment should take. We provide a basic guide below but we don’t know YOU like you know you.
No Symptoms to Mild Discomfort Once Yearly or Less Frequently
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 buttock cleft and use of No Bump Rx will help keep those follicles from blocking and rupturing. Use a coccyx cushion to keep pressure off the tailbone area and use proper posture when sitting. Keep an awareness of the buttock 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.
Mild Discomfort Several Times a Year
This is open for debate. Some doctors feel that any active Pilonidal should be treated with non-excision methods such as the Pit Picking, which involves removal of the buttock midline pits and drainage of the abscess. Super conservative doctors who advocate the complete non-surgical approach will advise to follow the approach listed above for “No Symptoms”. Again, keep an awareness of the cleft and check regularly for any increase in discomfort or drainage. If a problem is developing, you want to deal with it before it gets worse. Infections are serious business and need attention so they don’t turn into bigger, nastier infections that become increasingly harder to treat.
Acute Infection Several Times a Year
An acute infection (needing to be lanced or antibiotics) is a red-flag of a growing problem that your immune system is failing to manage. An abscess that is infecting regularly is one that is probably getting bigger and possibly forming new sinuses; the longer treatment is delayed, the worse the problem may be getting. If you are headed in for a lancing, try IF AT ALL possible to get a Pit Picking done 10 days later when the swelling has gone down. That may stop the progression of the disease before it gets worse.
Acute Infection Monthly or More Often
This is a problem that needs attention. It is disrupting your life and putting your body in state of constant crisis. 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.
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/Modified Karydakis flap. Failure of the more conservative methods usually indicates that there is a larger problem that needs more exploration of where other pits and sinuses might be hiding and being missed. Opening up the abscess area fully to find ALL the tracts that lead to pits may be the only solution when Pit Picking fails.
Failure of Excision Surgery
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 buttock (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 buttock 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. A really good doctor never hesitates to learn new techniques that will heal his/her patients. If you discover that you haven’t partnered with a good doctor, it may be time to find another one.
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This page last updated: January 3, 2019