Pilonidal disease Management Clinical assessment Elicit a disease-specific history and perform physical examination, emphasizing symptoms, risk factors, and presence of secondary infection. B Gluteal cleft hair removal ASCRS Q Does the patient have evidence of an abscess? Yes Perform incision and drainage in patients with a primary or recurring episode of acute pilonidal cyst associated with an abscess. B No 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 Antibiotic therapy SICCR Q Does the patient have severe cellulitis? Q Does the patient have immunosuppression? Q Does the patient have important concomitant systemic diseases? Yes to any Administer antibiotics in patients with immunosuppression, severe cellulitis or important concomitant systemic diseases. B No to all Phenol and fibrin glue injection ASCRS Q Does the patient have chronic pilonidal disease? Yes 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 No Continue management and follow-up as clinically appropriate. Excision and repair ASCRS Q Has the patient failed nonoperative measures for the management of chronic pilonidal disease? No Continue management and follow-up as clinically appropriate. Yes 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 Consider performing flap-based procedures, especially in the setting of complex and recurrent chronic pilonidal cyst when other techniques have failed. B Decide on operative strategy for recurrent pilonidal cyst distinguishing between the presence of an acute abscess and chronic disease, and taking into consideration the experience and expertise of the surgeon. B