Pilonidal Sinus: A Common Disease

by Dr. Patrick Balquet

History • Frequency • Clinical • Physical • Causes • Treatment Further Outpatient Care • Prognosis

History:


n 1830, Herbert Mayo could never have imagined that his description of a hair-containing sinus would be the subject of debate into the 21st century. Hodges coined the term pilonidal (pilus meaning hair and nidal meaning nest) in 1880.

As the name suggests, pilonidal disease consists of a hair-containing sinus or abscess in the sacrococcygeal area.

Congenital and acquired theories of etiology have been proposed. For a time, the entity was referred to as Jeep rider's disease. (It caused more than 80,000 US Army soldiers to be hospitalized during WWII and accounted for 4.2 million sick days !)

Presentations range from asymptomatic pits in the intergluteal region to painful draining lesions.

It has been established that pilonidal disease is an acquired condition involving midline pits in the natal cleft. These holes or pits are enlarged hair follicles in the skin. The nature of these distorted hair follicles is unclear. It has been suggested that gravity and motion of the gluteal folds create a vacuum that pulls on the follicle. Bacteria and debris enter this sterile area, producing local inflammation. Edema occludes the mouth of the follicle, which continues to expand, rupturing into the underlying fatty tissue. Keratin and pus escape, and a foreign body reaction results in a microabscess, which is similar to perforating folliculitis. The purulent material subsequently tracks within the presacral subcutaneous tissue, producing acute and chronic pilonidal abscesses.

The conversion from a microabscess to the burrowing infection defines pilonidal disease.

It was once thought that every pilonidal lesion contained a nest of hair. In reality, only 50% of cysts and sinuses are found to have hair during exploration.

Malignant degeneration rarely occurs in pilonidal disease

Frequency:

• The frequency is 30 to 40 cases per 100,000 population.

• Patients with pilonidal disease may seek advice for asymptomatic pits or holes in the natal cleft.
• Most patients seek medical attention for a history of progressive tenderness after physical activity or a period of prolonged sitting, such as during a long drive.
• Acute purulent drainage, pain, and/or swelling may be present.
• Systemic manifestations are rare, but patients may have malaise and fever.
• Twenty percent of symptomatic presentations are a result of an acute pilonidal abscess.
• Eighty percent of symptomatic presentations are exacerbations or manifestations of chronic disease.

• Presacral midline edema and/or nodule
• Fluctuance
• Purulent discharge from one or more lesions
• Tenderness to palpation
• Warmth
• Induration and/or cellulitis (usually minimal)
• Visible or palpable tracts of 2-5 cm in length in chronic or recurrent disease
• Fever (infrequent)

• Pilonidal disease involves a combination of skin and perineal flora.
  • Staphylococcus aureus is the most common organism.
  • Bacteroides species are the most common anaerobes.
    
    
• Risk factors include the following:
  • Male sex
  • Family predisposition
  • Obesity
  • Sedentary lifestyle
  • Repeated trauma
  • Occupation requiring prolonged sitting

Treatment:

• Asymptomatic pilonidal cysts require observation and instruction about local hygiene but since there is no inflammation,it is the best time for surgery:removal and primary skin closure can be done successfully
• At this stageand leads to a rapid healing after few days.
• Regarding acute pilonidal abscess, the consensus is to do a surgical treatment
  • It includes incision and drainage of the abscess under general anesthesia The contents, including hair and granulations, are evacuated, and then area is irrigated with copious amounts of fluid.
  • After Removal of all the sinus tissues, the wound stays
  • Then open with a packing dressing.
  • Quite a long time is needed before complete healing,generally a couple of weeks.
  • This approach leads to very good results and very low recurrence rates
  • Antibiotics are not necessary in most cases and should never be the primary mode of treatment.

• primary closure when not infected as preventive treatment
• removal and open wound until complete healing in infected cases.