Management of Pilonidal Abscess

Evidence Against Packing

The American College of Surgeons and other guideline societies recommend against packing a pilonidal abscess after incision and drainage, as it provides no proven benefit and increases pain and healthcare costs without improving healing time or reducing recurrence rates 1, 2
Packing is associated with increased pain during dressing changes and higher healthcare expenses due to prolonged use, with no evidence showing improvement in healing time, wound pain, fistula development, or abscess recurrence 1
The World Society of Emergency Surgery (WSES) 2021 guidelines make no recommendation regarding the use of packing after drainage of an anorectal abscess, based on the available literature 3

Placing a catheter or drain into the abscess cavity that drains into an external dressing, left in place until drainage stops, is a recommended alternative to traditional packing 1, 2
Warm water soaks or sitz baths starting 24-48 hours after drainage can promote healing 4

High recurrence rates (up to 44%) after simple drainage emphasize the need for complete and accurate initial drainage, with risk factors for recurrence including inadequate drainage, loculations, horseshoe-type abscess, and delayed time from disease onset to incision 1
One-third of perianal abscesses may develop a fistula-in-ano, increasing recurrence risk 1

Perform adequate incision and drainage without packing, and consider definitive procedures in appropriate candidates rather than simple drainage alone 1, 2
Instruct patients to begin warm soaks 24-48 hours post-procedure, and reserve antibiotics only for patients with fever >38.5°C, diabetes, immunosuppression, or surrounding cellulitis 3, 4
Monitor for recurrence given the 14-44% recurrence rate 1