Pilonidal Disease

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Pilonidal (pie luh NY dul) disease is a condition that affects mainly teenagers and young adults. A pilonidal sinus is a small hole that occurs under your skin between your buttocks cheeks, where the buttocks separate.  Usually, more than one sinus may be present.  Sometimes these are connected by tunnels under the skin. A pilonidal sinus can go unnoticed unless it becomes infected.  An infection causes a pus-filled abscess to develop. 

Cause

Although the exact cause of pilonidal sinus is not clear, there are various ways the condition can occur. It is generally felt that the pilonidal sinus is caused by loose hairs pushing into the skin. Hair follicles are the small holes that anchor each hair into the skin. Pressure and friction on hair follicles could redirect the follicle, causing the hairs to grow into the skin rather than outward. This does not become a problem until puberty when hair growth and oil production increase in the skin. 

Whatever the cause, a lot of hair growing between the buttocks is thought to be the main reason that problems develop from pilonidal disease.  Hair is often found trapped in this area and can cause inflammation and infection.  An infected pilonidal sinus often contains broken pieces of hair.

Risk Factors

Pilonidal disease affects more males than females. It typically occurs between the ages of 13 and 26 years. The following are some things known to increase your risk of pilonidal disease:

  • One or more family members has had this condition
  • A lot of body hair surrounds the sinus
  • Hair is coarse or curly
  • There is a deep gluteal cleft (deep crack in the buttock)
  • Over six hours per day is spent sitting
  • Shape and curve of the buttocks
  • Previous injury to the affected area
  • Poor hygiene
  • Overweight

Signs and Symptoms

You may have a pilonidal sinus and not have any noticeable symptoms. However, in most cases it will eventually become infected. If the sinus becomes infected an abscess will usually develop. An abscess is a collection of pus that forms in and around the sinus. Symptoms of an infected pilonidal sinus are:

  • Pain
  • The skin is red
  • Fever
  • Periodic drainage of blood or pus from the sinus
  • A tender lump under the skin, usually near the tailbone

Symptoms can develop quickly and will likely get worse without treatment.  Pain in the area will make it difficult to sit or lie down comfortably.

Treatment

If you have a pilonidal sinus that is not infected it is very important to keep the area as clean and dry as possible.  Hair and lint can collect in between the buttock cheeks.  You should take daily showers or baths to stay as clean as possible.  Wash and dry this area well to avoid an infection.

If you have a rapid onset of symptoms, you may be given some antibiotics to keep the infection under control.  If the pilonidal sinus keeps becoming infected, surgery may be recommended to remove the sinus to prevent further infections.

There are various treatments that can be done to cure pilonidal disease.  Your surgeon will be able to give the details and discuss each treatment.  These are the options:

Antibiotics

 If an infection is identified early, sometimes using antibiotics alone can stop it. If you feel pain that you think is the start of a recurrence of your disease, you should contact your doctor right away.

Incision and drainage with antibiotics

 If symptoms start quickly, it usually requires an incision to drain the sinus, along with antibiotics. The doctor opens the infected sinus and inserts a small straw-like drain to remove the pus. The drain is held in place by sutures (stitches). The drain will usually fall out on its own in about a week, but depending on how the procedure is done, sometimes you need to return to have the drain removed. This is a short operation that can be done at the hospital.

Afterward, a dry dressing is applied to collect any drainage. You will be taught how to change the dressing daily. Most people are able to return home after the drainage procedure.

Wide excision without closure

This operation involves cutting out the sinus or sinuses. The wound is left open and a sponge is placed into the cavity. The sponge is connected to a device known as a wound VAC. This device provides continuous suction that lets the wound heal from the inside out.  The wound should heal in about 6 to 10 weeks. You will need 2 to 3 dressing changes per week. A nurse may come to your home to help with these dressing changes. 

Excision and primary closure

This surgery involves removing the section of skin and underlying tissue that contains the sinuses. An oval-shaped cut is made to remove the sinuses.  Then, the two sides of the wound are stitched together. The advantage of this operation is that the wound heals very quickly. However, there is a higher risk of infection compared to leaving the wound open. If the area gets infected it will need to be opened and dressing changes performed.

The estimated recurrence rate is anywhere from 20 to 50 percent. Good personal hygiene is very important to help reduce the risk of recurrence. You need to keep the wound clean and free of any hair growing near the area. Even when the wound is healed, you should keep the area free of hair since excess hair greatly increases the risk that the condition will come back.

More Information

To get rid of excess hair and keep it from growing back in the area of the infected sinus, there are two methods to consider

  • Hair depilation and careful hygiene - Hair removal every other week with either a razor (shaving) or a depilatory cream such as Nair* has been shown to be effective in preventing recurrence.  Showering right after athletic activities or other activities where you are hot and sweating is typically recommended.  Daily showering and washing the area with soap and a washcloth is recommended because it provides a gentle daily exfoliation to the area in addition to keeping it clean.  Notably, do not shave or use cream depilation if you have an open wound without asking your physician first.
  • Laser hair removal - Laser hair removal is a more permanent treatment for removing body hair. It usually involves several sessions of laser therapy in the clinic. It has been shown to be an effective method for preventing pilonidal sinus disease from recurring. Trapped and excessive hair in and around the buttock is known to make recurrent infections more likely.  Permanent hair removal in the buttock area would eliminate the hairs and greatly reduce the risk of infection and recurrence. Unfortunately, most insurance companies will not cover the cost of using lasers for the medical treatment of pilonidal disease. They consider laser treatment to be a cosmetic procedure at this time.

A number of studies have found that laser hair removal greatly reduces the recurrence rate of pilonidal sinus disease.  If you would like to participate in a clinical trial for laser hair removal please contact us at 614-722-3909.

Pilonidal Disease (PDF)

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