Pilonidal Disease
What is pilonidal disease?
Pilonidal disease is a rather common condition involving the skin and the subcutaneous tissue of the natal cleft. Its twice as common in men than women, with a peak age onset at twenties.
Causes of pilonidal disease?
The contemporary belief is that the passage of hair into the subcutaneous tissues of the natal cleft triggers the disease process via mechanisms of friction, boring of hair shafts and local trauma. A chronic inflammatory process ensues with a foreign body reaction developing secondary to the presence of hair.
Risk factors for pilonidal disease
Risk factors include male gender, obesity, sedentary occupation (e.g. seated fr > 6h per day), family history, deep natal cleft with poor hygiene and hirsutism.
Symptoms of pilonidal disease
Clinical presentations are varied. Patients can present acutely with a superficial pilonidal abscess in the natal cleft, sub-acutely with recurrent infections, chronically with non-healing sinuses or symptomatically with a pilonidal cavity or pits.
Acute infections: fluctuant swelling in the natal cleft, with associated pain and redness
Chronic disease: sinus opening within the midline, hair may project from the opening, discharging blood or mucus-like fluid
How is pilonidal disease managed?
A consultation with your GP and subsequent referral to a colorectal surgeon will ensure that your symptoms are appropriately assessed and treated
The only definitive management of acute or chronic pilonidal disease is surgery
Conservative measures may include
Shaving or laser hair removal may be considered as first line therapy or in recurrent disease (should not be performed immediately post-operatively)
Weight loss
Improve perineal hygiene
Surgical management options for pilonidal disease:
Acute disease - Incision and drainage of abscess, removing granulation tissue, hair and debris to reduce recurrence rate. Leave pits alone. Treat with antibiotics if cellulitis is present.
Chronic / recurrent disease - Different approaches available. Decision for these approaches will be determined by the extent of disease, patient’s personal risk of infection or poor wound healing and surgeon’s expertise or preference
Minimally invasive - pit picking (usually in conjunction with abscess drainage), endoscopic treatment
Excision with secondary intention healing (open wound) - excision of disease but allow the wound to heal without closure. Wound care is resource intensive but it has relatively lower rate of wound infection when compared to primary closures
Excision with primary closure - excision of disease with preference for off-midline closure as it is associated with lower recurrence rates as compared to midline closures.
Excision with flap repair (e.g. Karydakis flap, Bascom cleft lip) - involves mobilising a flap across the midline, with excision of the skin, sinus tracts and midline pits, forming a lateralised wound. These techniques are associated with ~5% recurrence rate.