Management of Pilonidal disease: ASCRS Guideline

The American Society of Colon and Rectal Surgeons (ASCRS) has released guidelines on the management of Pilonidal disease. The purpose of these guidelines is to provide information on which decisions can be made rather than to dictate a specific form of treatment.

Pilonidal disease is an infection in the crease of a person’s buttocks, from the bottom of the spine to the anus. It is a potentially debilitating condition affecting ~70,000 patients annually in the US alone. The acquired condition is intimately related to the presence of hair in the gluteal cleft. Loose hairs trapped in the natal cleft traumatize and penetrate the skin, creating a foreign body reaction that may ultimately lead to the formation of midline pits and, in some cases, secondary infection.

Initial Evaluation

• A disease-specific history and physical examination should be performed, emphasizing symptoms, risk factors, and the presence of secondary infection.

Treatment

Nonoperative Therapy/ Nonoperative Adjunct

• Elimination of hair from the gluteal cleft and surrounding skin, by shaving or laser epilation, may be used for both acute and chronic pilonidal disease in the absence of abscess as a primary or adjunct treatment measure.


• In patients with acute or chronic pilonidal disease without abscess, phenol application is an effective treatment that may result in rapid and durable healing.


• In patients with chronic pilonidal disease without abscess, fibrin glue may be effective as a primary or adjunctive treatment of pilonidal disease.


• The value of prophylactic intravenous and topical prophylactic antibiotics in pilonidal disease surgery is not clear. Individualized consideration of their use is recommended.

Operative Management

• Patients with acute pilonidal disease characterized by the presence of an abscess should be treated with I&D regardless of whether it is a primary or recurring episode.


• Patients who require surgery for chronic pilonidal disease may undergo excision and primary repair (with consideration for off-midline closure), excision with healing by secondary intention, or excision with marsupialization based on surgeon and patient preference. Drain use should be individualized.


• Flap-based procedures may be performed, especially in the setting of complex and recurrent chronic pilonidal disease when other techniques have failed.


• Minimally invasive approaches to acute and chronic pilonidal disease that use endoscopic or video assistance may be used but require specialized equipment and expertise.

Management of Recurrent Pilonidal Disease

• Operative strategies for the recurrent pilonidal disease should distinguish between the presence of an acute abscess (section B1) and chronic disease (section B2), considering the experience and expertise of the surgeon.

For more information follow the link: The American Society of Colon and Rectal Surgeons’ Clinical Practice Guidelines for the Management of Pilonidal Disease