Pilonidal disease#Pilonidal sinus

File:Two pilonidal cysts in the natal cleft.jpg

Pilonidal cysts can be itchy and often very painful, and typically occur between the ages of 15 and 35. Although usually found near the coccyx, the condition can also affect the navel, armpit, the cheek,{{cite journal | vauthors = Adhikari BN, Khatiwada S, Bhattarai A | title = Pilonidal sinus of the cheek: an extremely rare clinical entity-case report and brief review of the literature | journal = Journal of Medical Case Reports | volume = 15 | issue = 1 | pages = 64 | date = February 2021 | pmid = 33563340 | pmc = 7874666 | doi = 10.1186/s13256-020-02561-z | doi-access = free }} or the genital region,{{cite journal | vauthors = Rao AR, Sharma M, Thyveetil M, Karim OM | title = Penis: an unusual site for pilonidal sinus | journal = International Urology and Nephrology | volume = 38 | issue = 3–4 | pages = 607–608 | date = December 2006 | pmid = 17111086 | doi = 10.1007/s11255-005-4761-5 | s2cid = 30090441 }} though these locations are much rarer.

Signs and symptoms may include:{{Cite web | vauthors = Sternberg J | url = http://www.pilonidalsurgery.com/what-is-it | title = What Is Pilonidal Disease | access-date = November 14, 2014 | archive-date = November 11, 2014 | archive-url = https://web.archive.org/web/20141111141653/http://www.pilonidalsurgery.com/what-is-it | url-status = live }}

• Intermittent pain/discomfort or swelling above the anus or near the tailbone
• Opaque yellow (purulent) or bloody discharge from the tailbone area
• Unexpected moisture in the tailbone region
• Discomfort sitting on the tailbone, doing sit-ups, or riding a bicycle—any activities that roll over the tailbone area

Some people with a pilonidal cyst will be asymptomatic.{{Cite web | vauthors=Doerr S | url=http://www.emedicinehealth.com/pilonidal_cyst/article_em.htm | title=Pilonidal Cyst | page=1 | work=eMedicineHealth | access-date=February 8, 2013 | archive-date=February 12, 2013 | archive-url=https://web.archive.org/web/20130212075205/http://www.emedicinehealth.com/pilonidal_cyst/article_em.htm | url-status=live }}

Pilonidal sinus (PNS): a sinus tract, or small channel, that may originate from the source of infection and open to the surface of the skin.{{cite web | title = PNS Acronyms | url = https://acronyms.thefreedictionary.com/PNS | work = thefreedictionary.com | access-date = 2018-01-03 | archive-date = 2018-01-04 | archive-url = https://web.archive.org/web/20180104073242/https://acronyms.thefreedictionary.com/PNS | url-status = live }} Material from the cyst drains through the pilonidal sinus. A pilonidal cyst is usually painful, but if it is a draining sinus, the pressure is relieved and the patient might not feel pain.

Hair insertion is the causative agent of pilonidal cysts.{{cite journal | vauthors = Bosche F, Luedi MM, van der Zypen D, Moersdorf P, Krapohl B, Doll D | title = The Hair in the Sinus: Sharp-Ended Rootless Head Hair Fragments can be Found in Large Amounts in Pilonidal Sinus Nests | journal = World Journal of Surgery | volume = 42 | issue = 2 | pages = 567–573 | date = February 2018 | pmid = 28639004 | doi = 10.1007/s00268-017-4093-5 | s2cid = 4705771 | url = https://boris.unibe.ch/101706/ }}{{cite journal | vauthors = Karydakis GE | title = Easy and successful treatment of pilonidal sinus after explanation of its causative process | journal = The Australian and New Zealand Journal of Surgery | volume = 62 | issue = 5 | pages = 385–389 | date = May 1992 | pmid = 1575660 | doi = 10.1111/j.1445-2197.1992.tb07208.x }} An analysis of 624 patients' cyst hair found that 74% of the hair was rootless, and resembled spiky, razor-cut hair rather than intact body hair. One proposed cause is ingrown hair,{{Cite web | url=http://www.mayoclinic.com/health/pilonidal-cyst/DS00747/DSECTION=3 | title=Pilonidal Cyst: Causes | publisher=Mayo Clinic | date=December 5, 2012 | access-date=February 8, 2013 | archive-date=October 25, 2008 | archive-url=https://web.archive.org/web/20081025123048/http://www.mayoclinic.com/health/pilonidal-cyst/DS00747/DSECTION=3 | url-status=live }} although hairs found in pilonidal sinus tracts have more often been found to originate from the head.

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; there are cases where this can occur months after a localized injury to the area.

Pilonidal cysts may be caused by a congenital pilonidal dimple.{{cite journal | vauthors = da Silva JH | title = Pilonidal cyst: cause and treatment | journal = Diseases of the Colon and Rectum | volume = 43 | issue = 8 | pages = 1146–1156 | date = August 2000 | pmid = 10950015 | doi = 10.1007/bf02236564 | s2cid = 189796851 }}

Excessive sweating can also contribute to the formation 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 developing pilonidal cyst.{{cite journal | vauthors = Bascom J, Bascom T | title = Failed pilonidal surgery: new paradigm and new operation leading to cures | journal = Archives of Surgery | volume = 137 | issue = 10 | pages = 1146–50; discussion 1151 | date = October 2002 | pmid = 12361421 | doi = 10.1001/archsurg.137.10.1146 | doi-access = }}

File:Relative incidence of cutaneous cysts.jpg

A pilonidal cyst can resemble a dermoid cyst, a kind of teratoma (germ cell tumor). In particular, a pilonidal cyst in the gluteal cleft can resemble a sacrococcygeal teratoma. Correct diagnosis is important because all teratomas require consultation with an oncologist and complete surgical excision, if possible without any spillage.

If there is an infection, treatment is generally by incision and drainage just off the midline because incisions in the midline have a hard time healing well. Following five simple rules has been known to prevent recurring inflammations for some people and avoid surgery: 1. Avoiding chairs and car seats that put pressure on the coccyx; 2. Being of average weight, preferably with low BMI; 3. Keeping the area clean; 4. Keeping the area dry by wearing exclusively cotton garments; 5. Keeping the area completely hair-free, for example, by regularly using an IPL hair removal device.{{cite journal | vauthors = Shafigh Y, Beheshti A, Charkhchian M, Rad FS | title = Successful treatment of pilonidal disease by intense pulsed light device | journal = Advances in Clinical and Experimental Medicine | volume = 23 | issue = 2 | pages = 277–282 | date = April 2014 | pmid = 24913119 | doi = 10.17219/acem/37077 | doi-access = free }}

The evidence for elective treatment of pilonidal sinus disease is poor.{{cite journal | vauthors = Brown SR, Lund JN | title = The evidence base for pilonidal sinus surgery is the pits | journal = Techniques in Coloproctology | volume = 23 | issue = 12 | pages = 1173–1175 | date = December 2019 | pmid = 31754976 | pmc = 6890656 | doi = 10.1007/s10151-019-02116-5 }} The most commonly performed surgery is for the pilonidal sinus complex to be surgically excised with the wound often left open to heal. Post-surgical wound packing may be necessary, and packing typically must be replaced daily for four to eight weeks. In some cases, two years may be required for complete granulation to occur. Sometimes the cyst is resolved via surgical marsupialization.{{cite journal | vauthors = Patel H, Lee M, Bloom I, Allen-Mersh TG | title = Prolonged delay in healing after surgical treatment of pilonidal sinus is avoidable | journal = Colorectal Disease | volume = 1 | issue = 2 | pages = 107–110 | date = March 1999 | pmid = 23577714 | doi = 10.1046/j.1463-1318.1999.00030.x | s2cid = 206172705 }}

A 2018 literature review of 740 records of surgeries that included recurrence rates found that primary midline closure surgeries resulted in a 67.9% recurrence rate within 20 years, and recommended that they should be discontinued due to the high recurrence rate.{{cite journal | vauthors = Stauffer VK, Luedi MM, Kauf P, Schmid M, Diekmann M, Wieferich K, Schnüriger B, Doll D | display-authors = 6 | title = Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence | journal = Scientific Reports | volume = 8 | issue = 1 | pages = 3058 | date = February 2018 | pmid = 29449548 | pmc = 5814421 | doi = 10.1038/s41598-018-20143-4 | bibcode = 2018NatSR...8.3058S }} Incision and drainage had a recurrence rate of 25.9% within 2 years, up to 40.2% in 5 years. Phenol treatment has a recurrence rate of 14.1% at 2 years and 40.4% at 5 years. A 2024 study involving 667 people found that, compared with tissue-removing surgery, minor procedures (such as draining and pit-picking) were associated with less pain, fewer complications and a faster recovery. However, minor surgeries were less likely to resolve the condition.{{Cite journal |last=Brown |first=Steven |last2=Hind |first2=Daniel |last3=Strong |first3=Emily |last4=Bradburn |first4=Mike |last5=Din |first5=Farhat Vanessa Nasim |last6=Lee |first6=Ellen |last7=Lee |first7=Matthew J. |last8=Lund |first8=Jonathan |last9=Moffatt |first9=Christine |last10=Morton |first10=Jonathan |last11=Senapati |first11=Asha |last12=Shackley |first12=Philip |last13=Vaughan-Shaw |first13=Peter |last14=Wysocki |first14=Arkadiusz Peter |last15=Callaghan |first15=Tia |date=2024-07-17 |title=Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation |url=https://www.journalslibrary.nihr.ac.uk/hta/KFDQ2017#/abstract |journal=Health Technology Assessment |language=EN |volume=28 |issue=33 |pages=1–113 |doi=10.3310/KFDQ2017 |issn=2046-4924|pmc=11284621 }}{{Cite journal |date=17 October 2024 |title=Pilonidal sinus: what type of surgery is best? |url=https://evidence.nihr.ac.uk/alert/pilonidal-sinus-what-type-of-surgery-is-best/ |journal=NIHR Evidence}}

Surgeons can also excise the sinus and repair it 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. This approach typically results in a more rapid recovery than traditional surgery; however, there are fewer surgeons trained in the cleft lift procedure, and it consequently may not be as accessible to patients, depending on their 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 healing time.{{cite journal | vauthors = Al-Khamis A, McCallum I, King PM, Bruce J | title = Healing by primary versus secondary intention after surgical treatment for pilonidal sinus | journal = The Cochrane Database of Systematic Reviews | volume = 2010 | issue = 1 | pages = CD006213 | date = January 2010 | pmid = 20091589 | pmc = 7055199 | doi = 10.1002/14651858.CD006213.pub3 }} Pilonidal cysts can 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. Minimally invasive techniques with no wound and rapid return to full activities have been reported but await double-blind randomized trials.{{cite journal | vauthors = Hardy EJ, Herrod PJ, Doleman B, Phillips HG, Ranat R, Lund JN | title = Surgical interventions for the treatment of sacrococcygeal pilonidal sinus disease in children: A systematic review and meta-analysis | journal = Journal of Pediatric Surgery | volume = 54 | issue = 11 | pages = 2222–2233 | date = November 2019 | pmid = 30940347 | doi = 10.1016/j.jpedsurg.2019.02.058 | s2cid = 88464026 | url = https://nottingham-repository.worktribe.com/output/1723008 }}

Another technique is to treat the pilonidal sinus with fibrin glue. This technique is of unclear benefit as of 2017 due to insufficient research.{{cite journal | vauthors = Lund J, Tou S, Doleman B, Williams JP | title = Fibrin glue for pilonidal sinus disease | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | pages = CD011923 | date = January 2017 | pmid = 28085995 | pmc = 6464784 | doi = 10.1002/14651858.CD011923.pub2 }} The evidence for any treatment is of low quality, and care must be taken not to overinterpret any study in this field.

Since the 2010s, several minimally invasive techniques have been developed to minimize the impact of surgery on patients and achieve less pain and shorter recovery times.{{cite journal | vauthors = Basso L, Pietroletti R, Micarelli A, Bicaj A, Costi U, Crocetti D, D'Ermo G, Gallo G | display-authors = 6 | title = The impact of experience on recurrence rates after biopsy punch excision for pilonidal disease | journal = Colorectal Disease | volume = 24 | issue = 8 | pages = 984–991 | date = August 2022 | pmid = 35344244 | pmc = 9541250 | doi = 10.1111/codi.16126 }}

In some cases, the wounds are left open after surgery to heal naturally instead of being closed with stitches. There are a lot of different dressings and topical agents (creams or lotions) that are available to help these open wounds heal. A 2022 systematic review brought together evidence from 11 studies that compared dressings and topical agents for treating open wounds after surgical treatment for pilonidal sinus of the buttocks.{{cite journal | vauthors = Herrod PJ, Doleman B, Hardy EJ, Hardy P, Maloney T, Williams JP, Lund JN | title = Dressings and topical agents for the management of open wounds after surgical treatment for sacrococcygeal pilonidal sinus | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 5 | pages = CD013439 | date = May 2022 | pmid = 35593897 | pmc = 9121912 | doi = 10.1002/14651858.CD013439.pub2 | collaboration = Cochrane Wounds Group }} The authors concluded that: platelet rich plasma may help wounds to heal quicker compared to sterile gauze; Lietofix skin repair cream may help wounds to heal by 30 days compared to iodine (which helps to reduce bacteria in the wound); but it is not clear whether hydrogel dressings (designed to keep the wound moist) reduce the time it takes wounds to heal compared with cleaning the wound with iodine.

Endoscopic pilonidal treatment, which uses a small camera to guide the surgeon in removing hair, is a newer method of treatment that has minimal pain and quick healing compared to surgery. A literature review of 497 patients found that the average endoscopic operation time was 34.7 minutes, and the average healing time was 32.9 days. Failure occurred in 8% of patients, who had persistent disease or recurrence.{{cite journal | vauthors = Emile SH, Elfeki H, Shalaby M, Sakr A, Giaccaglia V, Sileri P, Wexner SD | title = Endoscopic pilonidal sinus treatment: a systematic review and meta-analysis | journal = Surgical Endoscopy | volume = 32 | issue = 9 | pages = 3754–3762 | date = September 2018 | pmid = 29603009 | doi = 10.1007/s00464-018-6157-5 | s2cid = 4472852 }}

File:Pilonidal Cyst.png|Excised pilonidal cyst

File:Trephine surgery 1.png|Trephine/biopsy punch minimally invasive surgery for pilonidal disease (1)

File:Trephine surgery 2.png|Trephine/biopsy punch minimally invasive surgery for pilonidal disease (2)

File:Pilonidal cyst 2 days after surgery.jpg|Pilonidal cyst two days after traditional closed surgery

File:Pilonidal cyst and fistula.jpg|alt=Pilonidal disease removed|Anatomy of pilonidal disease removed after trephine or biopsy punch surgery: pilonidal fistula (top) and pilonidal cyst (bottom)

Pilonidal means 'nest of hair' and is derived from the Latin words for 'hair' ({{Lang|la|pilus}}) and 'nest' ({{Lang|la|nidus}}).{{Cite web | url=http://www.mayoclinic.com/health/pilonidal-cyst/DS00747 | title=Pilonidal Cyst: Definition | publisher=Mayo Clinic | date=December 5, 2012 | access-date=February 8, 2013 | archive-date=December 27, 2012 | archive-url=https://web.archive.org/web/20121227042313/http://www.mayoclinic.com/health/pilonidal-cyst/DS00747 | url-status=live }} The condition was first described by Herbert Mayo in 1833.{{Cite web | vauthors=Lanigan M | date=September 27, 2012 | url=http://www.emedicine.com/emerg/topic771.htm | title=Pilonidal Cyst and Sinus | work=Medscape | publisher=WebMD | access-date=February 8, 2013 | archive-date=October 22, 2008 | archive-url=https://web.archive.org/web/20081022025255/http://www.emedicine.com/emerg/TOPIC771.HTM | url-status=live }} R. M. Hodges was the first to use the phrase pilonidal cyst to describe the condition in 1880.{{Cite journal | vauthors=Hodges RM | year=1880 | title=Pilonidal sinus | journal=The Boston Medical and Surgical Journal | volume=103 | issue=21 | pages=485–586 | doi=10.1056/NEJM188011181032101 | url=https://zenodo.org/record/1803674 | access-date=2020-02-10 | archive-date=2021-08-28 | archive-url=https://web.archive.org/web/20210828224649/https://zenodo.org/record/1803674/preview/article.pdf | url-status=live }}{{cite book | veditors = Kanerva L, Elsner P, Wahlberg JE, Maibach HI |title=Handbook of occupational dermatology |year=2000 |publisher=Springer |location=Berlin |isbn=3-540-64046-0}}

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 bumpy rides in the vehicles were believed to have caused the condition due to irritation and pressure on the coccyx.

{{Reflist}}

{{Commons category|Sinus pilonidalis}}

• [https://www.nhs.uk/conditions/pilonidal-sinus/ NHS Choices for pilonidal sinus treatment]

{{Medical resources

| DiseasesDB = 31128

| ICD10 = {{ICD10|L|05||l|00}}

| ICD9 = {{ICD9|685}}

| ICDO =

| OMIM =

| MedlinePlus =

| eMedicineSubj = emerg

| eMedicineTopic = 771

| MeshID = D010864

}}

{{Bacterial cutaneous infections}}

Category:Buttocks

Category:Cysts

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