Wound Care Options for the Pilonidal Cyst

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Pilonidal Cyst

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

A pilonidal cyst is a pocket located at the top of the cleft of the buttocks that usually results from an embedded or stiff hair. This area may remain dormant for years and cause no major issues; however, often the embedded or stiff hair may cause the cyst to become inflamed and infected, resulting in an abscess that requires incision to drain the infected material. These abscesses can recur, causing the patient to require surgical intervention to remove the cyst. After surgery, some patients tend not to heal well, resulting in a chronic tracking wound in an area that is difficult to heal.

What Causes a Pilonidal Cyst to Develop?

Risk factors for pilonidal cyst include family history, sedentary job, extensive body hair, smoking, and obesity. It is more common among younger adults, with men affected three to four times more often than women. Friction from clothing, tight clothing, or sitting for prolonged periods may also cause the area to become inflamed.

Why are these wounds so difficult to heal? Location, offloading, pressure from clothing, and cleansing are issues that can impede the healing of a pilonidal cyst. It is not uncommon for up to 50% of pilonidal cysts to recur.

Wound Care Management for Pilonidal Cysts

Initially, treatment of the pilonidal cyst involves incision and drainage of the area. Oral antibiotics are not usually required given that the infection is localized. After the area has been incised, wound care involves daily irrigation with sterile water or wound cleanser in a syringe and packing of the wound because the wound will need to heal from the base up. As the wound begins to heal, less packing will be required. It is important to fill the wound and to not pack tightly because this can impede healing. It is important to ensure that the patient has a caregiver who can assist with wound care because these wounds are usually difficult for the patient to manage, given the location. The greatest impact on healing is offloading. Make sure the patient understands that he or she needs to keep pressure off the area while it is healing, as well as avoiding shear and friction. The patient should avoid prolonged sitting and tight clothing. Moisture management is also important and can be achieved with an absorptive dressing unless the patient has a large amount of drainage, which may require negative pressure. No tub baths should be taken while the wound is healing or acutely inflamed.

Patient Education

Once the wound is healed, the patient must be educated on methods to help prevent the recurrence of pilonidal cysts. The patient should be educated on cleansing techniques, hair removal, offloading, and clothing choices. The patient needs to be educated that keeping the area clean is very important. The patient may use cleansing wipes after toileting. Some infectious disease doctors recommend chlorhexidine showers twice weekly, leaving the chlorhexidine in place for one minute and then rinsing. Many patients benefit from laser hair removal. The patient has to understand the importance of offloading and avoiding prolonged sitting because this is a major risk factor, as outlined earlier. The patient should avoid clothing that can cause friction and pressure such as jeans or tight non-breathable clothing, as well as thongs.

What if the cyst does not close after surgery? Sometimes failure to close after surgery may result in the patient's having to return to surgery. Returning to surgery can complicate issues related to increased scar tissue, which does not heal as well as normal tissue. If surgical revision is not an option or has been attempted more than once with no closure of the wound, the goals for this wound then become to manage infection, attempt to reduce or maintain size of wound, provide appropriate dressing materials that optimize ease of care, minimize pain through the use of comfortable dressings and topical anesthetics, and routinely monitor the wound. Advanced therapies may also be utilized to reduce the size of the wound. The patient's nutrition should be addressed to ensure that he or she is eating the proper foods and getting adequate hydration. As with any non-healing wound, a wound culture would be warranted, as well as a biopsy, to rule out any malignancy. Other comorbidities should be addressed such as diabetes, smoking, and the use of anticoagulants.

Suggested Readings
Almajid FM, Alabdrabalnabi AA, Almulhim KA. The risk of recurrence of pilonidal disease after surgical management. Saudi Med J. 2017;38(1):70–4.
Fahrni GT, Vuille-dit-Bille RN, Leu S, et al. Five-year follow-up and recurrence rates following surgery for acute and chronic pilonidal disease: a survey of 421 cases. Wounds. 2016;28(1):2–6.
Marza L. Reducing the recurrence of pilonidal sinus disease. Nurs Times. 2013;109(25):22–4.
Mayo Clinic. Pilonidal cyst. 2018. https://www.mayoclinic.org/diseases-conditions/pilonidal-cyst/symptoms-c.... Accessed December 30, 2018.

About the Author
Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN is a Nurse Practitioner at the VA Medical Center in Lake City, Florida. She is the Wound Care Provider in the Out-Patient Clinic serving the Veteran Population of North Florida and South Georgia. Cathy is certified in wound, ostomy and foot care. In addition to her wound care experience, she also has experience in acute care, pediatrics, home health, long-term care and has served as a Professor of Nursing. Cathy’s passion for wound care began while she was working in the long-term care setting as an RN. She serves the veteran population as a memorial to her dad, a combat wounded WWII Veteran.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

Good article. I just finished healing a 20 year old male about 300 lbs his cyst was surgically removed and came to me for remainder wound healing. It measured 7 x 6 x 10. I did a wound vac for a few weeks, weekly debridements and then Switched over to prisma.

I thank the author for this but have several issues with her recommendations. Anyone who has read a high school biology book and understands the simple concepts of osmosis and diffusion will understand that using plain water on an open wound is likely to cause cellular rupture. Wound cleansers and even normal saline are isotonic and therefore allow for cleansing without damaging the cells. This is the same reason why using whirlpools with open wounds is condemned.

Recognizing that the human body is at 98.6° and that is the ideal temperature for all of the enzymatic processes that take place, most wound care specialists are aware that uncovering the wound allows the temperature to drop 6-8° while also disrupting the healing wound surface. It takes 6 to 8 hours once recovered for the wound to reestablish its microenvironment.
Unless the drainage was excessive, daily dressing changes have been shown to slow down healing by disrupting the internal wound milieu and more, dramatically increasing the cost related to wound healing based on the cost of a daily dressing change and the nursing time it takes to do so. Modern care specialists normally change wounds 2 to 3 times a week unless there is disruption of the dressing and/or excessive strikethrough.

The concept of "packing" an open wound is one that needs further explanation. Since the contact between a particular dressing and the walls of the wound (such as if a calcium alginate were used) is what promotes the healing effects, then “packing” a large quantity of it in the wound would provide little benefit since the vast majority would not be in contact with the wound surface and simply there to absorb drainage. My own preference is to “wallpaper” the wound surface with the appropriate dressing choice and then potentially place a less expensive but absorbent medium to fill the middle space of that wound. And again, the less done to the wound in the name of healing allows the wound to establish its own microenvironment and heal that much faster. The author is correct that any packing placed should be done loosely as pressures greater than approximately 32 mmHg will impact detrimentally on capillary blood flow.

Cathy, this is a great article & I really appreciate you sharing your knowledge on a wound care topic that many generalist will come into contact with & not understand the underlying etiology. You did a fabulous job on explaining this in terms that most anyone could understand. Thanks for contributing!

I appreciate the excellent summary of this important, but often neglected, wound type. The pain from pilonidal cysts is often quite disabling, and because they occur primarily among young, working-aged population, patients with this condition may be impatient, desiring quick healing and freedom from pain. They also may be reluctant to take opioid pain medications because they cannot be impaired while they are at work. Independence is often a strong value of this population, as well.

A recent case series with IRB approval in Canada (1) and a comparative study in Belgium (2) and both found that the polymeric membrane dressing (PMD) cavity filler, PolyMem WIC, is an excellent dressing choice for pilonidal cyst surgical incision wounds. This should not be surprising, because these dressings reduce pain, focus inflammation, and continuously cleanse - addressing each of the main reasons why these wounds often fail to heal.(3) In the Belgian study, pain at dressing changes was reduced from 8/10 to 3/10, wound cleansing was rarely required, and there were no recurrences when PMDs, rather than conventional dressings, were used. In both studies, patients were usually able to perform their own dressing changes, decreasing the frequency of nursing visits and resultant costs significantly.

Previously, Tamir (4) found that the use of the mesh-reinforced PMD cavity filler PolyMem WIC Silver Rope on an extremely painful infected pilonidal cyst cavity without prior surgical excision led to dramatic pain reduction (from 10/10 to 2/10), patient independence in dressing changes, a clean wound, and resolution of the narrow, deep wound in only one month. The patient, who had been unable to perform dressing changes independently due to pain with conventional dressings, had no difficulty removing and replacing the PMD.

1. Sibbald RG, Persaud Jaimangal R, Coutts PM, Elliott JA. Evaluating a Surfactant-Containing Polymeric Membrane Foam Wound Dressing with Glycerin in Patients with Chronic Pilonidal Sinus Disease. Advances in Skin & Wound Care. 2018 Jul;31(7):298.
2. Vanwalleghem G. A New Protocol for the Treatment of Pilonidal Cysts. Poster 293 presented at: European Wound Management Asssociation (EWMA); 2011 May 25; Brussels Belgium.
3. Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Management. 2016 Jun 15;62(6):42–50.
4. Tamir J. Extremely Painful Pilonidal Cyst Infection Resolved Quickly and Easily Using New Reinforced Rope Dressing. Poster #36 presented at: 8th Annual American Professional Wound Care Association (APWCA); 2009 Apr 2; Philadelphia, PA USA.

Sincerely,
Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA
Independent Nurse Researcher, and Clinical Research &
Education Liaison, and Charity Liaison for Ferris Mfg. Corp.

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