Pilonidal disease: Gaps in the guidelines and future perspectives

Pilonidal disease (PD) is an increasingly common condition that predominantly affects the young population. The variety of treatment modalities described in the literature makes it nearly impossible to design a study capable of definitively identifying the optimal method. As a result, treatment strategies are broadly categorized into minimally invasive and excisional approaches, with the choice often tailored to the severity and complexity of the disease on an individual basis. Currently, four major guidelines and consensus reports have been published on PD: The American (1), German (2), and Italian (3) guidelines, as well as the most recent guideline from the European Society of Coloproctology (ESCP) (4) in 2024. While these guidelines share certain points of agreement, they also diverge on several issues, and most of their recommendations are based on expert opinion or very low levels of evidence. Furthermore, many questions frequently encountered by surgeons in daily practice are either not addressed or remain unanswered in these guidelines.