Surgery is the treatment of choice. Ideally, a patient should undergo elective excision of the entire pilonidal sinus system and primary closure of skin when there is no infection present in any of the sinuses. Minimal excision, and packing using a local anesthetic in the ED results in reoccurrence. Patients presenting with acute inflammation should have their abscess drained in the ED. Their wounds should be allowed to heal, and then, at least 6 weeks later, if there is no evidence of active infection, they should be referred for definitive surgical excision.
The technique for incising and draining a pilonidal abscess is as follows: Place the patient prone on the proctoscopic table with the buttocks retracted laterally. The patient should receive conscious sedation. Tuck an ABD pad between the lower gluteal cleft to prevent the prep solution from pooling at the anus or genitals. After having prepped the skin, infiltrate the area to be incised with an intradermal injection of anesthetic solution, using a fine-gauge needle. A suction apparatus should be available to aspirate the unusually foul-smelling pus that has accumulated within the abscess. Following drainage, gently break down any loculations that may be present and loosely pack the wound with iodoform gauze. A bulky dressing should then be applied and secured with tape. The patient should be given a prescription for a strong oral analgesic and advised to begin hot sitz baths the following day. Before the sitz bath, the patient should remove the outer dressing but should not attempt to remove the packing until after having soaked in hot water for a few minutes. Ideally, one should allow the warm water current to flush the packing out of the wound. The patient should be seen in 48 to 72 h for evaluation and further advice concerning wound management.
Unless the patient is immunocompromised or there is cellulitis, there is no need to obtain cultures or prescribe antibiotics for an abscess that has been adequately drained.
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