Pilonidal Disease

DESCRIPTION

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

EPIDEMIOLOGY

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%) creating a pilonidal cyst

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

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

HISTORY

Three distinct clinical presentations

• Asymptomatic: painless cyst or sinus at the top of the gluteal cleft; fever is rare.
• Acute abscess: severe pain, swelling, and/or 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
• Inflamed sinus accompanied with one or more pits with or without hair debris
• Less common: significant cellulitis of the surrounding tissues near the gluteal cleft

DIFFERENTIAL DIAGNOSIS

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

DIAGNOSTIC TESTS & INTERPRETATION

Generally, no tests are needed since it can be diagnosed clinically.

GENERAL MEASURES

• Shave hair area; remove hair from crypts weekly.
• Asymptomatic disease does not need surgical treatment.

MEDICATION

• Antibiotics are not indicated unless there is a 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 is not indicated.
• Antibiotics only if significant cellulitis and abscess; temporizing, not curative
• Negative pressure wound therapy
• Laser epilation of hair in the gluteal fold (2)[B]
• Phenol infusion treatment can be used, especially for recurring disease.

SURGERY/OTHER PROCEDURES

• Several surgical techniques have proposed with limited data on superiority of one over another.
• 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 (3)[A]
  • Excision of midline “pits” allows drainage of lateral sinus tracts (pit picking).
  • Pilonidal cystotomy: Insert probe into sinus tract, excise overlying skin, and close wound (4)[B].
  • Marsupialization: Excise overlying skin and roof of cyst, and suture skin edges to cyst floor (3),(5)[B].
  • Excision: use of flap closure; no clear benefit for open healing over surgical closure
  • 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 (3)[A].
  • Endoscopic pilonidal sinus treatment (EPSiT): minimally invasive procedure (6)
• Endoscopic treatment such as EPSiT (endoscopic pilonidal sinus surgery)
• Fibrin glue in conjunction with some type of minimally excision

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

• Severe cellulitis
• Large area excision

FOLLOW-UP RECOMMENDATIONS

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

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.

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

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