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The Definitive Guide to Pilonidal Abscess

Whether this is your first one, or it is something that you’ve had before, it is something that you will have to figure out how to deal with.

How do I know if I have a pilonidal abscess?

These usually present as a painful lump next to the gluteal crease. Usually, it is on one side or the other, but it can also be in the midline, or straddle the midline with lumps on both sides. It is usually pink or red, tender to the touch, and gets worse as the days go by.

If you have a spot where this has been happening intermittently, then you may be dealing with a pilonidal “sinus” rather than an “abscess”. These usually have a characteristic red, raised appearance. They usually will drain on their own, but on occasion need to be drained by a surgeon. These will not go away without surgical removal.

 

There are several ways to proceed

My main recommendation : Go see a doctor!

 

If you can, going to see a medical professional is the best course of action. However there are several kinds of doctors who treat pilonidal disease, and your particular geographic location may make one or the other more feasible.

  • The best approach is to call a general surgeon’s office, indicate that you have a pilonidal abscess that may need to be drained, and ask to get in to be seen today. (This is considered an emergency.)
  • Another alternative is to go to an Emergency Room or Urgent Care.
  • Or, to your primary care doctor.
  • Although dermatologists deal with problems in the skin, it would be an unusual dermatologist that has broad knowledge of how to deal with pilonidal disease.

What will they do when I get there?

Unfortunately, this is not consistent from one practitioner to another and one situation to another.

If they confirm the diagnosis of Pilonidal Abscess:

  • They may drain it in the office or emergency room.
  • They may schedule drainage in the operating room under anesthesia later in the day or the next day.
  • They may tell you it is not ready to be drained, and send you home with or without antibiotics.

Drainage is the best way to deal with these and usually provides immediate relief of the severe pain. Sometimes, the abscess is very obvious, near the surface, and is easily opened up and drained. Other times, it is deep and exactly where to open it up to facilitate drainage is unclear. In the unclear cases, performing the drainage under anesthesia in the operating room will be more successful and less painful.

It is OK to request that this be drained under anesthesia, even if it is not initially offered. However, this may entail outpatient admission to the hospital, labwork, waiting until it can be added to the OR schedule, and additional cost. But, it may be worth the extra rigamarole and expense.

My personal experience is that antibiotics and wishful thinking are often unsuccessful, and that early drainage will prevent several days of suffering.

Note: the terms “drainage”, “lancing” and “I&D” all mean the same thing.

This is an example of a well placed drainage incision. It is well off the midline and out of the crease. This photo was taken a few weeks after drainage and has healed in nicely.

This patient subsequently had a cleft-lift to prevent recurrence.

The characteristics of a good drainage procedure are:

  • It is drained early, so it hasn’t become too large
  • The drainage opening is large enough to allow it to drain well. An incision 1/2″-3/4″ is best.
  • It is drained off to one side or the other. If it is drained in the midline, down in the cleft, it may not completely heal.
  • It is not “packed”. These heal faster and better without anything being stuffed in the abscess cavity. The only reason to do that is there is bleeding that will not stop and the packing puts pressure in the cavity.

What kind of post-drainage care should I perform?

Of course, you should follow the instructions that you were given by the doctor who performed the drainage. But, in general little care is needed. I tell patients it is OK to shower, change the dressings twice a day until it stops draining, take the antibiotics given, and follow up with me in 1-2 weeks. By that time it is usually healed. If the drainage was performed down in the cleft, and in the midline it may take much longer to heal, or possibly, it won’t ever heal. If a month has gone by, and it is still open and draining, than further surgery is needed; and a cleft-lift is the best option.

What if I want to deal with this at home?

Although this is not optimal, in some situations it’s the best you can do because of your location or finances. In that case, what you want is for the abscess to come to the surface and drain by itself. DO NOT USE ANYTHING SHARP TO TRY TO DRAIN IT,  OR SQUEEZE IT TO GET IT TO DRAIN. The oldest and most successful strategy to get it to do this is to apply warm, moist compresses to the area for about 15 minutes at a time, four times per day. Some people swear by drawing salves, like PRID or Ichthammol. These consist of petroleum based moisturizing ointments, with some other homeopathic ingredients. There is probably no harm to using them, but studies have had difficulty proving any superiority to warm compresses alone. (Note: do not confuse this with “black salve” which is toxic and can severely and permanently damage tissues.)

Soaking in warm water is OK as well, and may help promote drainage, but there is no evidence that Epsom salts or antiseptics added to the water make any difference.

Topical antibiotics or antiseptics will not penetrate the skin far enough to actually kill the bacteria in an abscess. There is no harm in trying tea tree oil, Oxy pads, bacitracin or neosporin ointment – but you may find they have no effect. Oral antibiotics have a greater chance of reaching the inside of an abscess – but a general rule-of-thumb in the surgery world is that drainage is far better than antibiotics for most kind of abscesses.

This is what an abscess that is draining on its own looks like. If it drains through a tiny hole, which then seals up, it may not be enough to completely let this resolve.

If you can quickly get it to drain on its own, that’s great, and it may settle down completely once it drained. But, if you can’t get relief in 24-48 hours, you may have to seek medical attention anyway. If it drains a little, then stops, and doesn’t feel much better, then you probably need to have it looked at. If you let it go on too long, and it becomes too large, it is possible to develop a dangerous infection, and make it so that it takes much longer to settle down than it would if drained early. In general, as mentioned above, the best course of action is to get medical care from the start.

Can I come see you and have a cleft-lift at the same time as drainage of the abscess?

That is not something that I recommend. Having a cleft-lift at the same time as an abscess predisposes to having post operative problems with wound healing and recurrent infection. It is much better to have the abscess drained, and a cleft-lift a week or two later when the infection has resolved, and the abscess cavity had decreased in size.

OK. Then what?

If the site of drainage has not healed in a month or six weeks, then you need a more definitive procedure sooner rather than later. If you’ve been reading my website, then you know that my preference is the cleft-lift operation done by someone experienced in the procedure.

If the site of drainage has nicely healed, then a decision has to be made regarding whether to proceed with a cleft-lift, or not. If this is your first abscess, you may want to wait and see whether you have further problems. If you have had this before, then I would encourage you to have a cleft-lift.

Just, keep in mind that the drainage procedure you had was just to get you through the painful abscess. It plays no role in preventing this from coming back, and it is remarkable how many physicians who drain these do not educate their patients about this fact.

We have had numerous patients remark to us that having an abscess was much more painful and difficult to recover from then the cleft-lift operation. This web page has a discussion of what to do if you had an abscess, everything healed up, and you are wrestling with the decision of what to do next.

If you have more questions, this FAQ page about pilonidal abscess may be helpful.