Synopsis
Distinguish an acute pilonidal abscess from asymptomatic pits or chronic sinus disease, select appropriate drainage or definitive surgery and follow the wound to an observed outcome.
- Pilonidal disease usually presents as midline natal-cleft pits with a cavity or lateral drainage opening; examine the perianal area to distinguish an anal fistula.
- A painful acute abscess needs adequate drainage, usually through a lateral incision; antibiotics alone are not a curative treatment for the cavity.
- Asymptomatic pits do not require prophylactic excision; symptomatic chronic or recurrent disease needs an individual definitive-treatment discussion.
Key red flags
Fever, extensive cellulitis or rapid deterioration requires urgent infection assessment alongside the local wound examination.
An opening close to the anal canal without convincing natal-cleft pits may arise from an anal fistula.
A longstanding nonhealing lesion with new induration, ulceration or changing tissue warrants assessment for an alternative diagnosis including malignancy.
Investigation priorities
Establish the likely origin and extent of a typical pilonidal presentation.
Management branches
A 27-year-old man has recurrent drainage from several pits after two previous abscess episodes.
- He is currently systemically well. Examination shows three midline pits and a lateral chronic opening clearly separated from the anal verge, with no acute collection or lesions in other folds. The surgeon maps the recurrent disease and discusses minimal approaches, open healing and off-midline excision/closure, including dressing burden and the uncertainty of future recurrence.
- Because of the extent and previous episodes, he chooses excision with an off-midline cleft-flattening closure performed by an experienced surgeon. There is no untreated infection requiring a therapeutic postoperative antibiotic course. He leaves with an individual analgesic and wound plan, help for dressings and advice to report increasing pain, redness, fever or wound separation.