Pilonidal disease, common in adolescents and young adults, is linked to hair insertion, friction, and bacterial colonization. Risk factors including obesity, sedentary lifestyle, and hirsutism should be addressed with initial non-operative management. Acute disease is primarily managed by incision and drainage; the addition of deroofing identified pits at the time of drainage can reduce recurrence. Management of chronic pilonidal disease is focused on removal of pits with the possible addition of marsupialization or primary closure. Closures with flap-based techniques, such as Karydakis and Bascom’s cleft lift, offer a lower recurrence rate but higher complication risks.