Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic

1st line – hair removal and perineal hygiene

Back
ACUTE
|
asymptomatic
1st line – 

hair removal and perineal hygiene

Surgery is not indicated in asymptomatic patients. Although data is limited in asymptomatic disease, conservative treatment with hair removal, improved perineal hygiene, weight loss, and avoiding prolonged sitting can be considered as it is low risk.[14]

symptomatic with abscess

1st line – incision and drainage and/or unroofing and curettage

Back
ACUTE
|
symptomatic with abscess
1st line – 

incision and drainage and/or unroofing and curettage

All acute pilonidal abscesses should undergo prompt incision and drainage. Depending on patient presentation and facility resources, it is ideal to debride all inflammatory debris and visible hair within an abscess cavity.[14]​ In one randomised controlled trial comparing unroofing and curettage of the abscess to standard drainage, 96% of patients in the curettage group had complete wound healing within 10 weeks, compared with 79% of patients in the drainage group. Recurrence was also significantly less in patients treated with the curettage instead of simple drainage (11% vs. 42%).[15]

Consider – antibiotic therapy

Back
ACUTE
|
symptomatic with abscess
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

There is no conclusive evidence to support routine use of peri-procedural antibiotics, although expert opinion has suggested a role in patients with significant cellulitis after surgical drainage or those with underlying immunosuppression, high risk of endocarditis, methicillin-resistant Staphylococcus aureus (MRSA), or concurrent systemic illness.[16][17]​ If antibiotics are indicated, amoxicillin/clavulanate is sufficient coverage. If amoxicillin/clavulanate is contraindicated, a fluoroquinolone (e.g., ciprofloxacin) combined with metronidazole is adequate.

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[18]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

Primary options

amoxicillin/clavulanate: 500 mg orally three times daily

More

Secondary options

ciprofloxacin: 750 mg orally twice daily

and

metronidazole: 500 mg orally three times daily

Consider – hair removal and perineal hygiene

Back
ACUTE
|
symptomatic with abscess
Consider – 

hair removal and perineal hygiene

Additional treatment recommended for SOME patients in selected patient group

​Recurrence rates following simple drainage have been reported as high as 55%.[17]​ Following drainage, conservative strategies including perineal hygiene and cleft hair removal by either shaving, laser, or depilatory cream should be utilised to minimise recurrence rates. Of note, razor/cream depilation in the immediate postoperative rate has been associated with a higher recurrence rate. One systematic review on postoperative hair removal showed that postoperative laser epilation was associated with a lower recurrence rate (9%) than razor/cream depilation (23%) and no hair removal after surgery (20%).[19]

symptomatic chronic or recurrent disease

1st line – surgical treatment

Back
ACUTE
|
symptomatic chronic or recurrent disease
1st line – 

surgical treatment

Surgical therapy is the mainstay of treatment for pilonidal sinus and aims to remove all the diseased tissue. Many surgical techniques have been described, but the optimal procedure is still controversial because of high recurrence rates and associated morbidity. Surgical options include excision with delayed wound closure, excision with midline primary closure, excision with primary off-midline closure (flap-based techniques), sinusectomy (aka trephination/Gips procedure), and endoscopic pilonidal sinus treatment.[4][14]​​

The available literature suggests that surgical treatment should be tailored specifically to the patient taking into consideration recurrence rates, wound complication rates, time to healing, and time to return to activities.

Consider – hair removal and perineal hygiene

Back
ACUTE
|
symptomatic chronic or recurrent disease
Consider – 

hair removal and perineal hygiene

Additional treatment recommended for SOME patients in selected patient group

One systematic review on postoperative hair removal showed that postoperative laser epilation was associated with a lower recurrence rate (9%) than razor/cream depilation (23%) and no hair removal after surgery (20%).[19]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer