Guideline sources The following summarized guidelines for the evaluation and management of pilonidal disease are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2019), the German National Guideline (GNG 2016), and the Italian Society of Colorectal Surgery (SICCR 2015). 1 2 3 Pathway Pilonidal disease Management Guidelines 1. Diagnostic investigations Clinical assessment: elicit a disease-specific history and perform physical examination, emphasizing symptoms, risk factors, and presence of secondary infection. B https://web.pathway.md/diseases/recDXRi8qZ8vYbx60 1/4 6/29/23, 11:11 PM Pilonidal disease Pathway 2. Medical management Antibiotic therapy: as per SICCR 2015 guidelines, administer antibiotics in patients with immunosuppression, severe cellulitis or important concomitant systemic diseases. B 3. Nonpharmacologic interventions Gluteal cleft hair removal: As per ASCRS 2019 guidelines, consider offering elimination of hair from the gluteal cleft and surrounding skin by shaving or laser epilation as a primary or adjunct treatment measure in patients with both acute and chronic pilonidal cyst without abscess. C As per SICCR 2015 guidelines, consider offering gluteal cleft shaving as a primary or adjunctive treatment measure, in the absence of an abscess. B 4. Therapeutic procedures Phenol and fibrin glue injection: As per ASCRS 2019 guidelines: Consider applying phenol in patients with acute or chronic pilonidal cyst without abscess. B Consider administering fibrin glue as a primary or adjunctive treatment in patients with chronic pilonidal cyst without abscess. C As per GNG 2016 guidelines, consider applying phenol in selected patients with pilonidal disease. C As per SICCR 2015 guidelines, consider administering phenol and fibrin glue injection in selected patients with chronic pilonidal disease. C 5. Perioperative care Perioperative antibiotic prophylaxis: As per ASCRS 2019 guidelines, insufficient evidence to support the use of IV or topical antibiotic prophylaxis for pilonidal cyst surgery. Consider administering antibiotic prophylaxis on an individualized basis. I As per GNG 2016 guidelines: Insufficient evidence to support the use of preoperative and/or postoperative antibiotic prophylaxis. I Consider administering one-dose empiric antibiotic prophylaxis. C 6. Surgical interventions General principles: As per GNG 2016 guidelines: https://web.pathway.md/diseases/recDXRi8qZ8vYbx60 2/4 6/29/23, 11:11 PM Pilonidal disease Pathway Perform surgery for the treatment of symptomatic patients with pilonidal disease. B Do not offer any treatment in asymptomatic patients with pilonidal disease. D As per SICCR 2015 guidelines, individualize treatment according to the severity of pilonidal sinus pathology. B Incision and drainage: As per ASCRS 2019 guidelines, perform incision and drainage in patients with a primary or recurring episode of acute pilonidal cyst associated with an abscess. B As per GNG 2016 guidelines: Insufficient evidence to recommend subcutaneous drainage in patients undergoing wound closure. I Perform incision and drainage in most patients with pilonidal abscess. B As per SICCR 2015 guidelines, perform incision and drainage to treat pilonidal abscess, regardless of whether the abscess is a primary or recurrent episode. Recognize that lateral incision can shorten healing time. B Excision and repair: As per ASCRS 2019 guidelines, consider performing any of the following excision procedures (with individualized drain use) based on surgeon and patient preference in patients with chronic pilonidal cyst requiring surgery: excision and primary repair (with consideration for off-midline closure) excision with healing by secondary intention excision with marsupialization. B Show 2 more As per GNG 2016 guidelines, recognize that off-midline procedures are associated with lower recurrence rates than midline closure and shorter time to complete wound healing and faster return to work than open healing. A Show 6 more As per SICCR 2015 guidelines, perform sinus excision in patients with an acute abscess rather than chronic inflammation, and in patients with recurrent disease after treatment. B Show 2 more Minimally invasive surgery: As per ASCRS 2019 guidelines, consider performing minimally invasive surgery using endoscopic or video assistance in patients with acute and chronic pilonidal cyst, recognizing that it requires specialized equipment and expertise. C As per GNG 2016 guidelines: Consider performing pit picking and its variations in previously untreated patients with minimal disease. C Insufficient evidence to recommend sinusectomy, recognizing that it is a promising minimally invasive method limited to patients with 1-3 midline pits. I As per SICCR 2015 guidelines, consider performing conservative and minimally invasive techniques in patients with mild-to-moderate disease. B https://web.pathway.md/diseases/recDXRi8qZ8vYbx60 3/4 6/29/23, 11:11 PM Pilonidal disease Pathway 7. Follow-up and surveillance Postoperative hair removal: Do not offer postoperative shaving. D Insufficient evidence to recommend postoperative laser hair removal. I Clinical findings Patient demographics Symptoms Male sex Intergluteal region discharge Intergluteal region pain Past medical history Social history Age < 30 Obesity Occupation requiring prolonged sitting References 1. Johnson EK, Vogel JD, Cowan ML et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis Colon Rectum. 2019 Feb;62 2 146 157. Open 2. Segre D, Pozzo M, Perinotti R et al. The treatment of pilonidal disease: guidelines of the Italian Society of Colorectal Surgery SICCR . Tech Coloproctol. 2015 Oct;19 10 607 13. Open 3. I Iesalnieks, A Ommer, S Petersen et al. German national guideline on the management of pilonidal disease. Langenbecks Arch Surg. 2016 Aug;401 5 599 609. Open 4. Steele SR, Perry WB, Mills S et al. Practice parameters for the management of pilonidal disease. Dis Colon Rectum. 2013 Sep;56 9 1021 7. Open https://web.pathway.md/diseases/recDXRi8qZ8vYbx60 4/4