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Pilonidal Disease

BASICS

DESCRIPTION

  • Pilonidal disease results from an abscess, or sinus tract, in the upper part of the natal (gluteal) cleft.
  • Synonym(s): jeep disease

EPIDEMIOLOGY

Incidence

  • 16 to 26/100,000 per year
  • Predominant sex: male > female (3 to 4:1)
  • Predominant age: 2nd to 3rd decades, rare >45 years
  • Ethnic consideration: whites > blacks > Asians

Prevalence

Surgical procedures show male:female ratio of 4:1, yet incidence data are 10:1.

ETIOLOGY AND PATHOPHYSIOLOGY

Pilonidal means "nest of hair " ; hair in the natal cleft allows hair to be drawn into the deeper tissues via negative pressure caused by movement of the buttocks (50%); follicular occlusion from stretching, and blocking of pores with debris (50%).

  • Inflammation of SC gluteal tissues with secondary infection and sinus tract formation
  • Polymicrobial, likely from enteric pathogens given proximity to anorectal contamination

Genetics

  • Congenital dimple in the natal cleft/spina bifida occulta
  • Follicular-occluding tetrad: acne conglobata, dissecting cellulitis, hidradenitis suppurativa, pilonidal

RISK FACTORS

  • Sedentary/prolonged sitting
  • Excessive body hair
  • Obesity/increased sacrococcygeal fold thickness
  • Congenital natal dimple
  • Trauma to coccyx

GENERAL PREVENTION

  • Weight loss
  • Trim hair in/around gluteal cleft weekly
  • Hygiene
  • Ingrown hair prevention/follicle unblocking

DIAGNOSIS

HISTORY

Three distinct clinical presentations

  • Asymptomatic: painless cyst or sinus at the top of the gluteal cleft
  • Acute abscess: severe pain, swelling, discharge from the top of the gluteal cleft that may or may not have drained spontaneously
  • Chronic abscess: persistent drainage from a sinus tract at the top of the gluteal cleft

PHYSICAL EXAM

  • Common: inflamed cystic mass at the top of the gluteal cleft with limited surrounding erythema ± drainage or a sinus tract
  • Less common: significant cellulitis of the surrounding tissues near the gluteal cleft

DIFFERENTIAL DIAGNOSIS

  • Furunculosis
  • Hidradenitis suppurativa
  • Anal fistula
  • Perirectal abscess
  • Crohn disease

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • Consider CBC and wound culture but generally not necessary for less-severe infections.
  • MRI might be considered to differentiate between perirectal abscess and pilonidal disease.

TREATMENT

GENERAL MEASURES

Shave area; remove hair from crypts weekly.

MEDICATION

  • Antibiotics not indicated unless there is significant cellulitis (1).
  • If antibiotics are needed, a culture to direct therapy might be useful.
  • Cefazolin plus metronidazole or amoxicillin-clavulanate are often used empirically if cellulitis is suspected.

ISSUES FOR REFERRAL

  • Patients who cannot comply with frequent dressing changes required after incision and drainage (I&D)
  • Patients who have recurrence after I&D
  • Patients who have complex disease with multiple sinus tracts

ADDITIONAL THERAPIES

  • I&D with only enough packing to allow the cyst to drain; overpacking not indicated
  • Antibiotics only if significant cellulitis; temporizing, not curative
  • Negative pressure wound therapy (2)[A]
  • Laser epilation of hair in the gluteal fold (3,4)[B]

SURGERY/OTHER PROCEDURES

Six levels of care based on severity or recurrence of disease; recent innovations in technique are aimed at expediting healing and minimizing recurrence

  • I&D, remove hair, curette granulation tissue (5,6)[A].
  • Excision of midline "pits " allows drainage of lateral sinus tracts (pit picking) (7,8)[A].
  • Pilonidal cystotomy: Insert probe into sinus tract, excise overlying skin, and close wound (7,9)[B].
  • Marsupialization: Excise overlying skin and roof of cyst, and suture skin edges to cyst floor (5,10)[B].
  • Excision: use of flap closure. No clear benefit for open healing over surgical closure (11)[B]
  • Off-midline surgical excision (cleft lift or modified Karydakis procedure): A systematic review showed a clear benefit in favor of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management (5,7,12)[A].

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Severe cellulitis
  • Large area excision

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Frequent dressing changes required after I&D
  • Follow-up wound checks to assess for recurrence.

Patient Monitoring

Monitor for fever, more extensive cellulitis.

PATIENT EDUCATION

  • Wash area briskly with washcloth daily.
  • Shave the area weekly.
  • Remove any embedded hair from the crypt.
  • Avoid prolonged sitting.

PROGNOSIS

  • Simple I&D has a 55% failure rate; median time to healing is 5 weeks.
  • More extensive surgical excisions involve hospital stays and longer time to heal.

COMPLICATIONS

Malignant degeneration is a rare complication of untreated chronic pilonidal disease.

REFERENCES

11 Mavros MN, Mitsikostas PK, Alexiou VG, et al. Antimicrobials as an adjunct to pilonidal disease surgery: a systematic review of the literature. Eur J Clin Microbiol Infect Dis. 2013;32(7):851 " 858.22 Farrell D, Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature. J Wound Ostomy Continence Nurs. 2011;38(4):373 " 378.33 Loganathan A, Arsalani Zadeh R, Hartley J. Pilonidal disease: time to reevaluate a common pain in the rear! Dis Colon Rectum. 2012;55(4):491 " 493.44 Oram Y, Kahraman F, Karincao lu Y, et al. Evaluation of 60 patients with pilonidal sinus treated with laser epilation after surgery. Dermatol Surg. 2010;36(1):88 " 91.55 Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am. 2010;90(1):113 " 124, Table of Contents.66 Kement M, Oncel M, Kurt N, et al. Sinus excision for the treatment of limited chronic pilonidal disease: results after a medium-term follow-up. Dis Colon Rectum. 2006;49(11):1758 " 1762.77 Al-Khamis A, McCallum I, King PM, et al. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2010;(1):CD006213.88 Iesalnieks I, Deimel S, Kienle K, et al. Pit-picking surgery for pilonidal disease [in German]. Chirurg. 2011;82(10):927 " 931.99 da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon Rectum. 2000;43(8):1146 " 1156.1010 Aydede H, Erhan Y, Sakarya A, et al. Comparison of three methods in surgical treatment of pilonidal disease. ANZ J Surg. 2001;71(6):362 " 364.1111 Washer JD, Smith DE, Carman ME, et al. Gluteal fascial advancement: an innovative, effective method for treating pilonidal disease. Am Surg. 2010;76(2):154 " 156.1212 Ates M, Dirican A, Sarac M, et al. Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg. 2011;202(5):568 " 573.

ADDITIONAL READING

  • Aygen E, Arslan K, Dogru O, et al. Crystallized phenol in nonoperative treatment of previously operated, recurrent pilonidal disease. Dis Colon Rectum. 2010;53(6):932 " 935.
  • Bradley L. Pilonidal sinus disease: a review. Part one. J Wound Care. 2010;19(11):504 " 508.
  • Harlak A , Mentes O, Kilic S , et al. Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors. Clinics (Sao Paulo). 2010;65(2):125 " 131.
  • Rao MM, Zawislak W, Kennedy R, et al. A prospective randomised study comparing two treatment modalities for chronic pilonidal sinus with a 5-year follow-up. Int J Colorectal Dis. 2010;25(3):395 " 400.
  • Theodoropoulos GE , Vlahos K , Lazaris AC , et al. Modified Bascom 's asymmetric midgluteal cleft closure technique for recurrent pilonidal disease: early experience in a military hospital. Dis Colon Rectum. 2003;46(9):1286 " 1291.

CODES

ICD10

  • L05.91 Pilonidal cyst without abscess
  • L05.92 Pilonidal sinus without abscess
  • L05.01 Pilonidal cyst with abscess
  • L05.02 Pilonidal sinus with abscess

ICD9

  • 685.1 Pilonidal cyst without mention of abscess
  • 685.0 Pilonidal cyst with abscess

SNOMED

  • 432863009 pilonidal disease (disorder)
  • 47639008 cyst - pilonidal (disorder)
  • 85224001 pilonidal cyst with abscess (disorder)
  • 311453002 Pilonidal sinus of natal cleft
  • 76545008 pilonidal cyst without abscess (disorder)
  • 200715006 Pilonidal sinus without abscess
  • 431709001 Pilonidal abscess of natal cleft

CLINICAL PEARLS

  • Avoid prolonged sitting.
  • Lose weight.
  • Trim hair in gluteal cleft weekly.
  • Refer recurring infections for more definitive surgical management.