Management of Pilonidal Disease

Section 1. Diagnosis of pilonidal disease:

·  We recommend the diagnosis of pilonidal disease clinically based on history and physical examination, with identification of midline pits, sinus tracts, and/or abscess formation in the sacrococcygeal region, (Strong recommendation, high certainty evidence, ⁽⁶⁾).

·  We recommend a thorough patient history including risk factors such as obesity, sedentary lifestyle, family history, and recurrent infections to guide management, (conditional recommendation, low certainty evidence, ⁽⁶⁾).

· Ultrasound or MRI may be recommended in recurrent or complex cases to assess the extent of sinus tracts and rule out other pathologies (e.g., perianal fistula, hidradenitis suppurativa), (conditional recommendation, moderate certainty evidence, ⁽¹⁾).

Section 2. Management of acute abscess:

·  We recommend incision and drainage (I&D) for the treatment of acute pilonidal abscesses, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

· Routine postoperative antibiotics are not recommended unless there is evidence of cellulitis or systemic infection, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

Section 3. Non-operative treatment of PNS:

·  In patients with acute or chronic pilonidal disease without abscess, phenol application may be recommended as an effective treatment that may result in rapid and durable healing, (Strong recommendation, moderate certainty evidence, ⁽⁶⁾).

·  In patients with chronic pilonidal disease without abscess, fibrin glue may be recommended as a primary or adjunctive treatment of pilonidal disease, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

Section 4. Minimally invasive techniques for treatment of PNS:

·  Endoscopic pilonidal sinus treatment (EPSiT) or pit-picking (Bascom’s procedure) may be recommended for selected patients with limited disease, (conditional recommendation, moderate certainty evidence, ⁽⁶⁾).

Section 5. Laser treatment of PNS:

·  Laser surgery may be recommended to patients with PD, (conditional recommendation, very low certainty evidence, ⁽¹⁾).

Section 6. Surgical treatment of PNS:

· We recommend open healing, (secondary intention), in presence of infection as it has lower recurrence rate, (conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·  We recommend closed techniques, (primary closure), in absence of infection as it offer faster healing, (conditional recommendation, moderate certainty evidence, ⁽¹⁾).

· Off-midline closure techniques (e.g., Karydakis flap, Limberg flap) for Chronic/Recurrent Disease are recommended over midline closure due to lower recurrence rates, (Strong recommendation, high certainty evidence, ⁽⁶⁾).

Section 7. Post-operative care of PNS:

·  We recommend proper wound hygiene and follow-up to monitor healing, (Good practice statement).

·  We recommend regular hair removal (laser or shaving) in the sacrococcygeal region to reduce recurrence, (Good practice statement).