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Surgical excision
9%
5/58
Cefazolin and metronidazole
0%
0/58
Use of hot compresses
10%
6/58
Incision and drainage
78%
45/58
Ensure dryness and cleanliness in the affected area
3%
2/58
Select Answer to see Preferred Response
This man presents with an acute abscess in the gluteal cleft, has a job that involves prolonged sitting, and plays a sport that involves sweating, most consistent with a pilonidal cyst. For an acute presentation with no sinus tract formation, incision and drainage is the treatment of choice. Pilonidal cysts can arise acutely as abscesses. They should be treated like other abscesses with incision and drainage under local anesthesia. The wound should be packed afterwards to allow for closure by secondary intention. If the cyst recurs, which is common, surgical excision of all sinus tracts with flap reconstruction is the definitive treatment. Figure A shows an erythematous abscess in the gluteal cleft, consistent with pilonidal cyst. Incorrect Answers: Answer 1: Surgical excision of the cyst is not indicated at this time, as this is the first presentation and is an acute abscess. If the cyst recurs, en bloc excision of the entire pilonidal sinus and all epithelialized tracts down to the sacrococcygeal fascia is required to prevent recurrence. Answer 2: Cefazolin and metronidazole would be an appropriate first-line antibiotic choice for a pilonidal cyst. However, this is only indicated if there is a presence of cellulitis and would not be recommended as the sole therapy. Incision and drainage or surgical excision would be performed the same time that antibiotics are initiated. Answer 3: Use of hot compresses can be helpful in managing abscesses, as it reduces swelling and inflammation. However, for a cyst that has enlarged over time and is causing significant pain, more direct intervention is required. Answer 5: Ensuring dryness and cleanliness in the affected area is a good idea, as sweat is thought to be a trigger for pilonidal cysts. However, given that this patient’s cyst has become enlarged and very painful, a simple change in hygiene would not be sufficient for treating it. Bullet Summary: Pilonidal cysts occur secondary to poor hygiene/exposure to sweat and present as acute abscesses that should be treated with incision and drainage.
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