A pilonidal cyst is a common skin condition affecting the crease of the buttocks near the tailbone (coccyx). This condition involves the formation of a small pocket under the skin, often containing hair and skin debris. The term “pilonidal” means “nest of hair,” reflecting the cause: loose hairs penetrating the skin. This penetration causes a foreign body reaction, leading to chronic inflammation and often subsequent infection. If the cyst becomes infected, it develops into a painful abscess—a swollen collection of pus requiring medical attention.
Initial Assessment and Referral
Patients typically first consult primary care providers, such as a Primary Care Physician or an Urgent Care provider. These professionals evaluate symptoms and determine the condition’s severity. For an acute pilonidal abscess, their immediate focus is managing the infection and providing pain relief. This often involves incision and drainage, where the abscess is lanced and the pus is released to alleviate pressure and reduce swelling.
While antibiotics may be prescribed to address surrounding cellulitis or skin infection, they are usually insufficient to resolve a large pus collection without drainage. Primary care providers confirm the diagnosis via physical examination, which rarely requires specialized imaging. Their primary function is to triage the case and initiate the appropriate referral. If the cyst is a simple, one-time infection that resolves completely after drainage, specialist intervention may not be necessary. However, if the disease is recurrent, complex, or involves multiple tracts, the patient is referred to a surgical specialist for definitive treatment.
Surgical Specialists for Definitive Treatment
When a pilonidal cyst becomes chronic or complex, requiring more than simple drainage, the patient is typically referred to a surgeon for definitive excision of the diseased tissue. The two main types of specialists who perform these procedures are General Surgeons and Colorectal Surgeons. Both are trained in the necessary surgical techniques. Colorectal Surgeons, who focus on the colon, rectum, and anus, often have advanced expertise in managing complex diseases of the perianal region, including pilonidal disease.
General surgeons are highly skilled and can manage many cases, including incision and drainage and traditional excision of the cyst. For recurrent or severe disease, the specialized knowledge of a colorectal surgeon can be beneficial, as they are more likely to be proficient in advanced reconstructive techniques. These advanced procedures are designed to remove the entire cyst and sinus tracts while promoting better wound healing and reducing the chance of the disease returning.
One common approach is a wide excision, where the cyst and all associated tracts are removed, leaving the wound open to heal from the bottom up, a process known as healing by secondary intention. More specialized techniques, such as flap procedures, are often employed by surgeons who focus on pilonidal disease. The Bascom Cleft Lift is an example of a flap procedure. It involves removing the affected tissue and reshaping the surrounding skin to flatten the natal cleft, reducing the deep crease where hair and debris accumulate. This surgical modification is a key strategy to lower the long-term recurrence rate. Specialists may also perform less invasive options, such as Endoscopic Pilonidal Sinus Treatment (EPSiT) or pit-picking, offering quicker recovery times for less complex cases.
Adjunctive and Long-Term Care Providers
Managing pilonidal disease extends beyond the initial diagnosis and definitive surgery, often involving other specialists focused on long-term care and recurrence prevention. Dermatologists, for instance, may become involved in the treatment plan, as the condition is a chronic inflammatory process of the skin and hair follicles. While they do not perform the primary excision surgery, dermatologists can offer non-surgical management.
The primary role of the dermatologist is the utilization of laser hair removal, or epilation, in the affected area. Since ingrown hair is a significant factor in the disease’s cause, removing hair permanently from the gluteal crease can reduce the foreign body reaction that triggers cyst formation. Laser treatment is often recommended either as an adjunctive measure after surgery to reduce recurrence or as a primary preventive treatment for mild disease.
Specialized Wound Care Nurses or Specialists also play a significant role in the recovery process. When the surgical wound is left open to heal by secondary intention, it requires consistent, meticulous care over several weeks or months. These specialists educate patients on proper wound hygiene, perform regular dressing changes, and monitor the wound for signs of infection or complications. Their expertise is instrumental in ensuring the surgical site heals correctly and completely, which is essential for achieving a lasting resolution of the disease.