Pilonidal disease

Pilonidal disease
Synonyms	Pilonidal cyst, pilonidal abscess, pilonidal sinus, sacrococcygeal fistula
Pilonidal cysts of sudden onset in the upper gluteal cleft
Specialty	General surgery, emergency medicine
Symptoms	Pain, swelling, redness, drainage of fluid[1]
Usual onset	Young adulthood[2]
Risk factors	Obesity, family history, prolonged sitting, greater amounts of hair, not enough exercise[2]
Diagnostic method	Based on symptoms and examination[2]
Differential diagnosis	Hidradenitis suppurativa, perianal abscess, folliculitis[2]
Prevention	Shaving the area[1]
Treatment	Incision and drainage[2]
Frequency	3 per 10,000 per year[2]

Pilonidal disease is a type of skin infection which typically occurs between the cheeks of the buttocks and often at the upper end.^[1][3] Symptoms may include pain, swelling, and redness.^[1] There may also be drainage of fluid.^[1] It rarely results in a fever.^[2]

Risk factors include obesity, family history, prolonged sitting, greater amounts of hair, and not enough exercise.^[2] The underlying mechanism is believed to involve a mechanical process.^[2] The lesions may contain hair and skin debris.^[1] Diagnosis is based on symptoms and examination.^[2]

If there is infection, treatment is generally by incision and drainage just off the midline.^[1][2] Shaving the area may prevent recurrence.^[1] More extensive surgery may be required if the disease recurs.^[1] Antibiotics are generally not needed.^[2] Without treatment the condition may remain long term.^[1]

About 3 per 10,000 people are affected a year and it occurs more often in males than females.^[2] Often it occurs in young adulthood.^[2] The term means "nest of hair".^[1] It was first described in 1833.^[1]

Signs and symptoms

Two pilonidal cysts that have formed in the gluteal cleft

Pilonidal cysts are itchy and are often very painful, and typically occur between the ages of 15 and 35.^[4] Although usually found near the coccyx, the condition can also affect the navel, armpit or genital region,^[5] though these locations are much rarer.

Symptoms include:^[6]

• Pain/discomfort or swelling above the anus or near the tailbone that comes and goes
• Opaque yellow (purulent) or bloody discharge from the tailbone area
• Unexpected moisture in the tailbone region
• Discomfort with sitting on the tailbone, doing sit-ups or riding a bike (any activities that roll over the tailbone area)

Some people with a pilonidal cyst will be asymptomatic.^[7]

Causes

One proposed cause of pilonidal cysts is ingrown hair.^[9] Excessive sitting is thought to predispose people to the condition, as sitting increases pressure on the coccygeal region. Trauma is not believed to cause a pilonidal cyst; however, such an event may result in inflammation of an existing cyst. However, there are cases where this can occur months after a localized injury to the area. Some researchers have proposed that pilonidal cysts may be the result of a congenital pilonidal dimple.^[10] Excessive sweating can also contribute to the cause of a pilonidal cyst. Moisture can fill a stretched hair follicle, which helps create a low-oxygen environment that promotes the growth of anaerobic bacteria, often found in pilonidal cysts. The presence of bacteria and low oxygen levels hamper wound healing and exacerbate a forming pilonidal cyst.^[11]

Diagnosis

Treatment

Treatment may include antibiotic therapy, hot compresses and application of depilatory creams. In more severe cases, the cyst may need to be lanced or treated surgically. Lancing is performed using a local anesthesia, with healing time generally under one week.^[12] The most conservative surgical treatment, Bascom's Pit Picking procedure, is a relatively simple outpatient option that can be performed in a physician's office, involves minimal pain and requires only a few days healing.^[13] Although this procedure is much less invasive than the alternatives, it is not regularly practiced in the US. The Pit Picking procedure provides good results, fast recovery, and in instances where it is unsuccessful, other options for more invasive surgery can still be performed.

The more common course for surgical treatment is for the cyst to be surgically excised (along with pilonidal sinus tracts). Post-surgical wound packing may be necessary, and packing typically must be replaced once daily for 4 to 8 weeks. In some cases, two years may be required for complete granulation to occur. Sometimes the cyst is resolved via surgical marsupialization.^[14]

Surgeons can also excise the sinus and repair with a reconstructive flap technique, such as a "cleft lift" procedure or Z-plasty, usually done under general anesthetic. This approach is especially useful for complicated or recurring pilonidal disease, leaves little scar tissue and flattens the region between the buttocks, reducing the risk of recurrence.^[11] This approach typically results in a more rapid recovery than the traditional surgery, however there are fewer surgeons trained in the cleft lift procedure and thus, it may not be as accessible to patients, depending on their geographic location. Meta analysis shows recurrence rates were lower in open healing than with primary closure (RR 0.60, 95% CI 0.42 to 0.87) at the expense of time to healing.^[15] Pilonidal cysts recur and do so more frequently if the surgical wound is sutured in the midline, as opposed to away from the midline, which obliterates the natal cleft and removes the focus of shearing stress. An incision lateral to the intergluteal cleft is therefore preferred, especially given the poor healing of midline incisions in this region.

An attractive minimally invasive technique is to treat pilonidal sinus with fibrin glue. This technique is less painful than traditional excisional techniques and flaps, can be performed under local or general anaesthesia, does not require dressings or packing and allows return to normal activities within 1 to 2 days. Long term outcome and recurrence rates are not dissimilar to more invasive techniques in 5 year follow up in a small randomised controlled trial.^{[16][17][18][19]} Fibrin glue has also been shown to be better than more invasive alternatives in the treatment of pilonidal sinus disease in children, where a quick return to normal activities and minimal postoperative pain are especially important.^[20]

A minimally invasive surgical technique, was developed in Israel by Moshe Gips et al.,2008.^[21] and is similar to the pit picking technique first described by Bascom in 1980^[22] In this procedure, trephines or biopsy punches which only "core out" and remove the diseased tissue and cyst are used, leaving only small holes to heal. Work or school activities will be resumed in one or two days, without or with minimal postoperative pain. The two procedures have been successfully combined by L. Basso in Rome (Italy).

While the recovery rate is positive for most, some suffer long term effects. Recorded instances include patients with continued postoperative pain for years following the surgical procedure. Primary complaints included pain when sitting for long period of times or following abrasive contact with the lower back and buttocks.

• 
  Excised pilonidal cyst
• 
  Trephine / biopsy punch minimally invasive surgery for pilonidal disease (1)
• 
  Trephine / biopsy punch minimally invasive surgery for pilonidal disease (2)
• 
  Pilonidal cyst two days after traditional closed surgery.
• 
  Anatomy of pilonidal disease removed after trephine or biopsy punch surgery: pilonidal fistula (top) and pilonidal cyst (bottom)

Etymology

Pilonidal means nest of hair and is derived from the Latin words for hair (pilus) and nest (nidus).^[4] The condition was first described by Herbert Mayo in 1833.^[23] R.M. Hodges was the first to use the phrase pilonidal cyst to describe the condition in 1880.^[24][25]

The condition was widespread in the United States Army during World War II. The condition was termed "Jeep seat" or "Jeep riders' disease", because a large portion of people who were being hospitalized for it rode in Jeeps, and prolonged rides in the bumpy vehicles were believed to have caused the condition due to irritation and pressure on the coccyx.

References

External links

• NHS Choices for pilonidal sinus treatment