[size=20px]A 16 year-old girl presents to your clinic with pilonidal disease. She previously had an incision and drainage performed, but continues to report intermittent pain, bleeding and drainage. On exam she has 3 midline pits, no current drainage of pus or blood and no obvious abscess cavity. Optimal management plan would be:

 

A Improved hygiene and laser epilation

 

B Improved hygiene, laser epilation and sinusectomy (pit excision) in clinic under local anesthesia

 

C Proceeding to the OR for pediatric endoscopic pilonidal sinus treatment (PEPSiT)

 

D Wide local excision of all pits and nidus of infection​[/size]

D

D

correct answer

B Improved hygiene, laser epilation and sinusectomy (pit excision) in clinic under local anesthesia

 

 

Study by Check et al. looked at their resolution rates in patients seen in their pilonidal care clinic with mild disease. Mild disease was defined as any number of midline pits 2mm or less in diameter with or without an obvious nidus. 77 of the 78 patients that followed up resolved their disease. Rafeeqi et al. published a very similar protocol with an 8% recurrence rate. Both of these protocols involve improved hygiene, laser hair removal (epilation), and excision of pits, either in the operating room or clinic.

 

Check et al. describe a successful method of administering local anesthesia, performing the laser hair removal, excising the pilonidal pits and closing individually with a stitch. If there is active nidus, it was left open. Repeat visits were scheduled every 6 to 8 weeks until all pit wounds are healed and follicles ablated, emphasizing the benefit of a dedicated clinic and a longitudinal program of care.

 

Though many different treatment options exist, wide excisions tend to be more morbid and a PEPSiT requires postoperative care that may be difficult for some adolescents to follow. Standardizing pilonidal care and a dedicated pilonidal care clinic may lead to less invasive and more successful treatment for this difficult disease.​