Draining a Pilonidal Abscess: Controversies and Best Practices
Draining a pilonidal abscess (I&D) should be in the bag of tricks of any emergency room, urgent care doctor, or surgeon. But the practice is very variable, and many patients have unsatisfactory experiences. Here are the main issues, and I will say this is somewhat controversial as while I feel that I am promoting well-established best practices, many doctors still endorse some old-fashion procedures.
1) When draining a pilonidal abscess, try and make the incision away from the midline if possible. Incision made in the buttock cleft midline are hidden and resist draining and healing, while those off to the side drain better and are more likely to heal over time. Sometimes, however, the abscess is only drainable in the midline, and this forces the doctor’s hand, and that’s OK if needed to adequately drain the abscess.
2) When draining a pilonidal abscess, doctors should make a larger rather than a small incision to facilitate drainage. Makes sense.
3) The shape of the incision is very important. Draining an abscess with a linear stab incision doesn’t permit drainage. Incisions need to be elliptical so that the skin doesn’t heal before the abscess fully drains. Elliptical incisions allow abscesses to drain over days and provide the most rapid recovery from an acute abscess. Aspiration with a needle and syringe is not a good practice and rarely if ever works. The easiest way to make an elliptical incision is to make a cruciate incision and cut the 4 triangular segments off.
4) Failure for an I&D wound to heal may be a consequence of the pilonidal abscess wanting to form a sinus and continue to decompress itself rather than a poorly performed I&D. This may be a natural progression of the disease process.
5) Lastly (and this may be the most controversial portion of this post), doctors should stop packing I&D wounds. I was taught to pack wounds during my residency but in fellowship I was taught the opposite and it has been a game changer. Packing wounds acts like a cork keeping infection inside. Having patients or their family members repack wounds is painful, embarrassing, and counterproductive. Incisions made to drain a pilonidal abscess should be elliptical, at least a centimeter in size, and not packed. After drainage patients should soak in a tub several times a day and they will typically feel better within 24 hours of the procedure, if not in hours. This is evidence based and here’s a useful article: