A pilonidal sinus is an abnormality in the natal cleft area just above the buttocks. Loose hairs fall off the neck or back and collect in the natal cleft. The hairs can cause small holes to form in the skin or can get into existing holes - called pilonidal sinus.
As the hairs carry infection, the holes can become infected. This causes a pilonidal abscess to form or a discharge that is released through a tunnel (sinus) out onto the skin.
Almost all patients present with either recurrent pain or a recurrent pus-like discharge from just above the buttocks.The condition usually affects young adults, occurring in 1 in 100 young men and 1 in 400 women.
Cause
There is some disagreement about what causes pilonidal cysts. Most pilonidal cysts appear to be caused by loose hairs that penetrate the skin. Friction and pressure - skin rubbing against skin, tight clothing, long periods of sitting, bicycling or similar factors - force the hair down into skin. Responding to the hair as a foreign substance, the body creates a cyst around the hair.
This explanation accounts for rare cases of pilonidal cysts that occur in other parts of the body. For example, barbers, dog groomers and sheep shearers have developed pilonidal cysts in the skin between fingers.
Another possible explanation is that normal stretching or motion of deep layers of skin causes the enlargement and rupture of a hair follicle, the structure from which a hair grows. A cyst then forms around the ruptured follicle.
Some children are born with a small indentation in the skin (sacral dimple) near the top of the cleft of the buttocks. Rarely, a sacral dimple may become infected, essentially forming a pilonidal abscess.
Reasons
A pilonidal cyst may cause no noticeable symptoms (asymptomatic). The only sign of its presence may be a small pit on the surface of the skin. When it's infected, a pilonidal cyst becomes a swollen mass (abscess).
Signs and symptoms of an infected pilonidal cyst include : -
Pain
Localized swelling
Reddening of the skin
Drainage of pus or blood from an opening in the skin (pilonidal sinus),
Foul smell from draining pus
Hair protruding from a pilonidal sinus
Fever (uncommon)
A pilonidal sinus may appear as a tract, a passage below the surface of the skin that connects the infected pilonidal cyst to the opening on the skin's surface. More than one sinus tract may form to drain a single infected cyst.
Treatment for an infected pilonidal cyst may include : -
Figure 1a - Wide excision for chronic pilonidal disease in a young male: preoperative marking of excision markings
Figure 1b - Two weeks post excision
Figure 1c - Four weeks post excision
Figure 1d - Eight weeks post excision
Figure 1e - Ten weeks post excision
Incision and drainage
The initial treatment for an infected pilonidal cyst, or pilonidal abscess, is usually a procedure performed by your primary care doctor or a surgeon. You're given a local anesthetic to numb the area before your doctor opens the abscess, drains the fluids and removes hair and other debris. The wound is packed with dressing so that it can heal from the inside out. For about 50 to 60 percent of people with an infected pilonidal cyst, this treatment is effective and no further treatment is needed.
Surgery
A surgical procedure is necessary if you have a recurring infected pilonidal cyst or if one or more sinus tracts are present. A surgeon will expose the cysts and all sinus tracts in order to clean out hairs, pus and other debris.
The preferred surgical procedures generally fall into two categories : -
Open wound : - The surgical wound is left open and packed with dressing to allow it to heal from the inside out. This process results in a longer healing time but usually a lower risk of a recurring pilonidal cyst infection.
Closed wound : - After cleaning out the cyst and sinus tracts, the surgeon stitches the wound closed. The healing time is shorter with these procedures, but there is a greater risk of recurrence. To improve healing time and lower the risk of recurrence, the surgeon may make the incision off to one side and create a flap of skin. Therefore, when he or she stitches the wound, it is not in the cleft of the buttocks, where healing is particularly difficult.
Wound care is extremely important after surgery. Your doctor or nurse will give you detailed instructions on how to change dressings, what to expect of a normal healing process and when to call the doctor. Postoperative care will also include shaving around the surgical site to prevent hairs from entering the wound.
Risk Groups
The risk groups for pilonidal sinuses are : -
Dark-haired, hirsute men.
Mens' hairdressers; sometimes get pilonidal sinuses in the webs between the fingers.
Farmers may develop pilonidal sinuses in their skin webs as a result of implanted hairs from farm animals.
About 75% of pilonidal sinuses occur in men, usually from the age of puberty to about 40 years of age, but rarely in older people.
Women who develop a pilonidal sinus tend to be younger. This is consistent with their earlier onset of puberty.
Patients tend to be, but are not invariably, dark, hairy, and they are often obese.
About half of patients present as acute emergencies with a pilonidal abscess.
Complications
Bleeding-which can occur either during or after surgery. The risk increases if the wound is left open. If the wound was closed with stitches, bleeding can result in a lump caused by a blood clot (haematoma), risk 3 in 50.
Unsightly scarring of the skin, it is common for the shape of the natal cleft to be deliberately changed, to help prevent the problem coming back.
A small percentage of people have an inherited tendency to scars that are unusually red and raised.
Complications of this operation
Partial breakdown of the wound, which is quite common if it is closed with stitches. The risk increases if there is an infection at the time of surgery that leads to the wound being infected (risk 1 in 4). The wound may then need to be packed until it has healed.
Slow healing, which can sometimes occur if the wound is packed. Healing usually takes about eight weeks but can take much longer (risk 3 in 100).
Recurrence of the pilonidal sinus: It is important to keep the area free from hairs and as clean as possible to reduce this risk (risk 1 in 9).
Numbness around the wound, which is quite common, but is not a major problem. (risk 1 in 9).
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