How Would you Handle This Presumed Pilonidal Cyst?

A 28-year-old female presented for evaluation of presumed pilonidal cyst of several years duration to discuss treatment options.

Your action plan is to:

A. Refer the patient to a general surgeon
B. Attempt to do a punch excision of the most symptomatic area to avoid excessive surgery
C. Prescribe a trial of antibiotics such as doxycycline for a month to see if there is clinical improvement before recommending surgery
D. Incise and drain the lesions 
E. Tell her she does not have a pilonidal cyst

(Answer and discussion on next page)

Answer: Tell her she does not have a pilonidal cyst. 

Because pilonidal cysts are typically a single larger cystic structure rather than clusters such as those seen here, it is unlikely this would be the diagnosis. Though considered rare— the true incidence is unknown with most cases being sporadic mutations—physical examination more correctly leads to a steatocystoma multiplex.
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In the classic presentation, cysts manifest during adolescence and early adulthood, with average age of onset of 26 years. A biopsy will confirm the diagnosis. Regrettably for the patient, treatments are rather limited and unsatisfactory.