Pilonidal Cyst

Dear Dr. B: My son is 18. About a year ago he had surgery for pilonidal disease in the tailbone area. The wound got infected and has not healed. The wound continues to drain bloody discharge. My son finds it very frustrating as it soils his clothes. Can you please tell me about pilonidal disease? Yours, Mrs. Z.

Dear Mrs. Z: The pilonidal disease most commonly occurs between the buttocks, close to the tailbone. This condition has been described since 1847. The term pilonidal means “hair-nest”. It can also occur in other areas such as beard, the armpit, the belly button and the web spaces of the hands (in barbers) and feet.

Pilonidal disease is a spectrum of three conditions: acute pilonidal abscess, chronic pilonidal abscess or sinus, and the unhealed pilonidal surgical wound.

For many years, experts believed that this was a congenital condition. In 1946, Patty and Scarff challenged this theory and drew attention to the role of hair in the origin of this problem. Current evidence strongly indicates an acquired origin for pilonidal disease, with most infections being related to penetration of the skin by hair through small midline pits.

Where do these pits come from? Some people believe they are congenital while others believe them to be enlargement of hair follicles. These pits have sinus openings through which the hairs penetrate. Hirsutism in the buttock and perineal area appears to be associated with the development of pilonidal disease.

Management of the condition depends on the type of presentation. Acute pilonidal abscess needs to be drained immediately once the diagnosis is made. The area should be kept shaved. Daily bath or shower will keep the area clean. Once healed, it may become necessary to excise the midline pits under local anaesthesia to prevent recurrence.

Treatment of chronic pilonidal abscess or sinus remains controversial as no one treatment has proved superior. The choices are: non-operative treatment with repeated phenol injections; conservative excision of the sinus openings and midline pits; laying open the sinus tract and stitch the skin margins to fibrous tissue (marsupialization); or wide excision with or without different types of closures of the skin.

The unhealed pilonidal surgical wound and recurrence of pilonidal disease after initial treatment is very common. Management of this problem can be very difficult. To start with, the unhealed wound should be curettaged to control the excessive granulation tissue (healing tissue which fills the wound), and the surrounding skin should be shaved weekly. The wound should be kept clean and dry with gauze. Strapping the buttocks apart may help prevent the continuous shearing movement during walking.

The wound may take six to eight weeks to heal. Quite often healing does not occur. Then a skin graft or some form of plastic flap may help the healing process. Overall, treating pilonidal disease should not be taken lightly as the results are quite often disappointing. If it ain’t broken then don’t fix it!

Finally, on a personal note, I would like to thank all those who phoned, e-mailed or sent messages through my family about last week’s column on my mother. The reaction from the readers was overwhelming. Many people reminded me that it is Mother’s Day this Sunday!

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