If your doctor has mentioned the word “excision,” you might already be looking for any other way out. Or a flare calmed down a few months ago and you’re still wondering if it’s actually gone.

What works depends on what you have, because a quiet pit in the skin and an abscess that has you walking funny need very different things.

The short answer is that a flare often settles without surgery, but the tract under the skin rarely disappears by itself. For a lot of people, hair removal and less pressure on the area keep things quiet for years.

If it keeps coming back, a few office procedures can close the tract without leaving a big wound. An abscess is different, because it needs draining.

Do pilonidal cysts go away?

Yes and no, which is where most of the confusion comes from. The part you can feel usually does go away. A flare is inflammation, and it calms down, sometimes by draining and sometimes by just shrinking back over a week or two.

What usually stays is underneath: one or more small pits in the cleft, with a tract below them where hair and debris collect. That’s why people describe their cyst as something that comes and goes. Each flare is usually the same tract acting up again rather than a new cyst.

Quiet stretches can last a long time, though. In a ten-year review of 513 patients at one health system, about a third of people treated with antibiotics alone had the disease come back. The other two thirds didn’t during follow-up, even though the tract was most likely still there.

You’ll also hear that it burns itself out after 40. New cases do become less common after about 25 and are rare after 45, but a cyst you already have is a different story. The surgeons at Evergreen Surgical’s pilonidal clinic say existing disease often doesn’t settle if it’s left untreated, and they’ve seen patients as old as 70 still dealing with it.

Is it okay to live with a pilonidal cyst?

For a lot of people, yes, it is. If you have a pit or two that hasn’t flared in a long time and doesn’t drain or hurt, many surgeons are happy to leave it alone. You keep the hair down and the area dry, and deal with it if it flares up.

It’s harder to justify when flares are regular. Each infection can push the tract deeper or open a new one off to the side, and disease with several openings usually needs a bigger operation. The surgical guidelines reserve flap procedures mostly for complex and recurrent disease, and that’s where long-running cases tend to end up.

If you’ve had one for years and worry it could be something worse, cancer in a pilonidal sinus is rare. It’s been found in as many as 0.1% of pilonidal sinus specimens, usually in disease left alone for decades. Still, if yours has been draining on and off for years and nobody has looked at it, get it checked.

What helps without surgery

You can start on the first three yourself, while the others need a doctor.

Get the hair out of the cleft

Pilonidal disease is a reaction to loose hair getting pushed into the skin, so removing the hair removes what feeds it. The American Society of Colon and Rectal Surgeons lists shaving or laser hair removal as a main or add-on treatment, as long as there’s no active abscess.

Shaving works, but it needs repeating every week or two and it’s awkward to do yourself, so plenty of people get help or use a hair removal cream instead. Test a cream on a small patch first, because the skin there is sensitive. Laser hair removal lasts much longer. In one US trial, adding it to standard care cut the chance of the disease coming back within a year from about a third to about a tenth.

Our guide to laser treatment covers the data and how to get insurance to pay for it.

Keep the cleft itself clear too, because loose hairs from your head and back collect there even if you shave.

Take pressure and moisture off the area

Sitting squeezes the cleft together, and the friction works loose hairs into the skin. A case-control study found that working seated was an independent risk factor, along with having more hair in the cleft.

You don’t need to quit your desk job. Get up every half hour or so, avoid long stretches on hard seats, wear loose cotton underwear and shower after anything that makes you sweat. At work, a cushion with a deep cutout at the back keeps the cleft off the seat. Skip the donut pillow, since its back edge presses right where you don’t want it. Our guide to choosing a cushion explains what to look for, and how to sit with a pilonidal cyst covers the positions.

We make one for this, called The Float. The cutout runs about 10 inches in from the back edge, roughly twice as deep as a typical coccyx cushion, so the whole cleft stays off the seat. It’s our own product, so weigh that, but the criteria in the cushion guide apply whichever one you buy.

Warm compresses during a flare

A warm compress a few times a day makes a flare easier to live with and sometimes helps a small collection come to the surface and drain. It’ll get you through a bad week, but it does nothing for the tract. Our warm compress guide covers how to do it and when not to.

Antibiotics: what they can and can’t do

Antibiotics treat infection in the skin around the cyst, but they can’t reach the hair and debris inside the tract. That’s why they calm a flare without ending the problem. In that same review, 36.7% of people treated with antibiotics alone had a recurrence, compared with 21.3% after surgical excision.

If a doctor prescribes them for spreading redness, finish the course, but don’t take feeling better as a sign the tract has healed.

Office procedures that aren’t a full operation

If flares keep coming back, the next step doesn’t have to be an operating room. These are usually done under local anesthetic and don’t leave a large open wound. You could call them surgery, but they’re a long way from an excision.

Phenol – The surgeon cleans out the tract and fills it with phenol, a chemical that destroys the lining so it scars shut. A 2024 meta-analysis of 14 studies and nearly 1,500 patients found recurrence wasn’t significantly different from surgery, with far fewer wound problems. People were back at work about 10 days sooner and healed about 17 days faster. The surgical guidelines call it effective for disease without an abscess.

Fibrin glue – The tract is cleaned and sealed with a medical glue. The same guidelines say it can work for long-standing disease without an abscess, alone or with other treatment.

Laser ablation – A thin laser fiber goes into the tract and burns the lining as it’s pulled back out. It’s often sold as SiLaC or SiLaT, and our laser guide has the recurrence data.

Not every surgeon offers all three, so ask before you book.

If there’s an abscess, drainage comes first

A hot, swollen, very painful lump that’s getting bigger by the day is probably an abscess, and home care won’t fix it. The usual first step is drainage, a small cut under local anesthetic to let the pus out. According to a summary of the surgical guidelines, it works in about 60% of people, while the other 40% or so need another procedure later.

If yours has already opened and is draining, here’s what to do next.

What doesn’t help (and what can make it worse)

Squeezing it or using a needle – It might feel better for a bit, but pressing pushes bacteria deeper and can turn one pocket into several.

Repeat courses of antibiotics with nothing else changing – Each course may calm a flare, but if the hair and pressure are still there, another one usually follows.

How long can you leave it untreated?

There’s no deadline, and plenty of quiet pits sit for years without trouble. These are the signs it’s time to do something:

• it keeps coming back
• new openings are appearing in or beside the cleft
• the lump is getting bigger between flares
• it drains most of the time rather than now and then
• it’s starting to limit how long you can sit or whether you go to the gym

Some signs mean today: a fever, redness spreading away from the area, pain that’s getting worse, or feeling unwell. They suggest the infection is spreading beyond the cyst and need urgent care or the ER.

When surgery becomes the better option

Surgery makes sense when you’ve given the non-surgical route a fair try and flares keep coming, when the disease has spread into several tracts, or when you’d rather deal with it once than manage it for years. Any of those is a good enough reason.

Options range from a small excision to a cleft lift, which flattens the cleft so it traps less hair. Our guide to pilonidal cyst surgery explains each one and what recovery looks like.

If you can, see a colorectal surgeon or someone who treats a lot of pilonidal disease. Results depend a lot on who does the work, and specialists are more likely to offer the less invasive options.

Bottom line

Most pilonidal cysts can be managed without an operation for a long time, and some never need one, even if the tract rarely disappears. For a quiet cyst, hair removal and less pressure do most of the work. If flares keep coming back, ask about phenol, fibrin glue or laser ablation before you agree to an excision.

For the whole non-surgical approach in one place, with routines and questions to take to your doctor, download our free guide, You Don’t Have to Get Cut Open.