Pilonidal Abscess FAQ

If a pilonidal cyst becomes acutely infected, it is now called a Pilonidal Abscess. The symptoms of this are severe discomfort; a red, tender lump; and possibly a fever. The natural course of these abscesses can very: it might drain on its own and subside, or it might not drain and require surgical drainage.

If you are experiencing this, the best option is to see a surgeon for diagnosis and treatment. If this is not something that you can do, it is possible to get this to drain with warm compresses to the area or soaking in a warm tub. The heat has a tendency to bring the abscess to a head so it can drain. Unfortunately, some of these infections are so deep that this never happens without surgical intervention. Antibiotics may be slightly helpful, but if an abscess really needs to be drained they will just postpone the inevitable.  The longer a patient waits, the larger the abscess may become, and the longer the healing process once it is drained.

Here are some answers to questions about pilonidal abscess

I had a pilonidal abscess drained, and now it looks and feels good. They told me I don’t have to do anything else.
It Depends

Although it is possible that you won’t have any further problems – many patients do go on to have recurrent problems months or years in the future. Some studies have found that about 50% of patients with an abscess go on to have further problems. According to Murphy’s Law, this usually occurs at the worst possible time, such as when you’ve just started a new job, have no insurance, are on vacation, are preparing to get married, etc. My advice is to consider having a definitive procedure, like a cleft-lift, in the near future at a convenient time. However, it is totally acceptable to take a “wait and see” approach as long as you are aware of the possible outcome. This is discussed further on the page: Pilonidal Disease with Minimal Symptoms.

A pilonidal abscess, after being drained, needs to be “packed”, and the gauze removed slowly over a period of time.
Usually False

Once drained (also referred to as “lanced”), a pilonidal abscess heals quickly. In my experience, packing the abscess cavity actually slows down the healing. Unfortunately, there is not universal agreement with my observations. I rarely insert packing or any kind of a drain for an acute abscess (unless it is enormous in size). As long as an adequate incision is made to properly drain the abscess, the infection will quickly resolve, the abscess cavity will close, and the patient will feel better very quickly. Antibiotics may help speed up the recovery – but are probably not absolutely essential. Packing is painful and scary.

The only way to drain a pilonidal abscess is in the clinic with local anesthesia

These can also be drained in the operating room with sedation or general anesthesia. How it is done depends on what the patient wants. If the abscess is clearly defined and ready to “pop”, it is usually pretty easy and quick to do this in the clinic. But, if the patient has pain – but the outward visible signs are vague – draining this in the operating room with IV sedation is my preference.

It is useful to culture the drainage from a pilonidal abscess.

This does not provide useful information. We find various different organisms, but the treatment is surgical drainage for an abscess, or a cleft-lift for chronic disease. When an abscess is drained, we usually start antibiotics based on our guess of the bacteria involved. By the time we have culture and sensitivity results, the abscess has usually resolved. Before a cleft-lift procedure, patients are treated with antibiotics that cover gram positive and gram negative and anaerobic bacteria. Studies of the kinds of bacteria involved show a preponderance of anaerobic bacteria, so antibiotics like metronidazole (Flagyl), Clindamycin or Augmentin are often used.

Antibiotic ointments will speed up healing.
In this situation antibiotic ointments do not make the abscess resolve more quickly or the open area heal faster. Some patients develop a rash from topical antibiotic ointments like Bacitracin, Neosporin or Polysporin. In addition, the ointments trap moisture and can make the bacterial situation worse than without them. So, I would say that they are not helpful, and may be counter-productive. The best local wound care is to keep the open area clean and dry; either a bath or shower is fine. The idea is to wash away the debris in as comfortable a method as possible. Then, keep a dry gauze pad over the area to absorb any new drainage.
Hydrogen peroxide is harmful to the wound.
The reason that this is often said is that hydrogen peroxide can be harmful to normal cells and slow wound healing. However, in the situation where you are dealing with inflamed, dead tissue with pus and exudate – it is a good antiseptic to decrease the number of bacteria (mostly to help with the odor), and its foaming action will help remove dead tissue and dried fluids. It will not significantly speed up resolution of the problem – but I don’t think it will have any harmful effects either.
Epsom Salt bath will speed up healing.
Mostly False
Soaking in a bath a few times a day to wash away drainage and debris is a good idea. The addition of Epsom Salts (magnesium sulfate) has not been proven to really speed up the resolution of the infection. Personally, I doubt it will hurt, but is probably not a necessary addition to the bath water.
The Chippewa River along the University of Wisconsin-Eau Claire