Management of Pilonidal Abscess

Patient Selection and Referral Criteria

For a pilonidal abscess in a fit, immunocompetent patient without systemic signs of sepsis, outpatient incision and drainage is appropriate and does not require referral to general surgery 1, 2, 3
The patient can be safely managed in the outpatient setting if they are young and fit with no significant comorbidities 1, 4
Immunocompetent patients (no immunosuppression, HIV, chemotherapy, or chronic steroids) are suitable for outpatient management 1, 2
Patients with no diabetes mellitus are eligible for outpatient care 2, 3
Patients without systemic signs of sepsis (no fever, tachycardia, hypotension, or altered mental status) can be managed outpatient 1, 2, 3
Patients with no extensive cellulitis or surrounding soft tissue infection are suitable for outpatient incision and drainage 1, 2

Patients with sepsis, severe sepsis, or septic shock require emergent drainage in the OR and should be referred immediately 1, 2, 4
Immunocompromised patients of any kind should be referred to general surgery 1, 2
Patients with diabetes mellitus (controlled or uncontrolled) should be referred to general surgery 1, 2
Patients with diffuse cellulitis extending beyond the immediate abscess area should be referred to general surgery 1, 2
Patients with complex anatomy (horseshoe abscess, suspected supralevator extension, or multiple loculations) should be referred to general surgery 4, 5

Incision and drainage under local anesthesia is the primary treatment for appropriate candidates 1, 4
The incision should be kept as close to the anal verge as possible to minimize potential fistula length while ensuring adequate drainage 1, 4
Complete drainage is essential, as inadequate drainage leads to recurrence rates as high as 44% 1, 4, 5

No routine antibiotics are needed after adequate drainage unless there is surrounding cellulitis or the patient is immunocompromised 2, 3
Wound packing is controversial, and evidence suggests it may be costly and painful without adding benefit 1, 5

Risk factors for recurrence include inadequate drainage, loculations, horseshoe-type abscess, and delayed treatment 1, 4, 5
Imaging is not routinely needed unless there is recurrence, suspected IBD, or non-healing wound 4, 5

Do not probe for fistulas during acute abscess drainage, as this causes iatrogenic complications 2, 3
Do not underestimate the extent of the abscess, and refer to surgery if complex anatomy or multiple loculations are suspected 4, 5