What is Pilonidal Cyst and Sinus?
The term ‘pilonidal’ comes from the Latin words ‘pilus’, which means ‘hair’, and ‘nidus’, which translates to ‘nest’. The term ‘pilonidal disease’ was first used by a man named R.M. Hodges in 1880. However, the condition was actually first described by O.H. Mayo back in 1833, and not long after, A.W. Anderson also detailed the condition and how to manage it in 1847. Many American soldiers were diagnosed with this condition during the wars, hence it was nicknamed ‘Jeep disease’.
What Causes Pilonidal Cyst and Sinus?
In the past, many doctors thought that pilonidal disease, a type of skin infection, was something people were born with. They believed it stemmed from remnants of the spinal cord, skin growths, or certain glands. But nowadays, experts understand pilonidal disease as something you acquire, not something you’re born with.
Patey and his colleagues put forth the idea that pilonidal disease comes from hair getting pulled into the skin and soft tissues around it. This leads the body to react as if it’s dealing with a foreign invader and creates a type of inflammation known as foreign body granuloma. Around the same time, King also supported the idea that pilonidal disease is acquired and results from the body reacting to a foreign object, leading to an infection.
Then, Karydakis simplified this idea even further. He broke down the cause of pilonidal disease into three main factors: the presence of hair or a foreign object, a force that pushes this hair or object into a tunnel in the skin (called a sinus), and a vulnerability of the skin itself.
Risk Factors and Frequency for Pilonidal Cyst and Sinus
Pilonidal disease is a condition that affects about 26 out of every 100,000 people. Men are seen to be affected 2.2 times more often than women. It’s estimated that each year, around 70,000 people in the United States are affected by pilonidal disease.
Signs and Symptoms of Pilonidal Cyst and Sinus
Pilonidal disease is typically diagnosed through a patient’s medical history, physical examination (including an exam of the rectum), and an assessment of their symptoms and risk factors. Key features doctors look for in a physical exam are pits in the upper part of the buttock crease, which may also be connected to sinuses that have formed either upward or to the side. Risk factors include being male, having a family history of the disease, being overweight or obese, experiencing trauma or constant irritation in the area, leading a sedentary lifestyle or having a job that involves long periods of sitting, having a lot of body hair, and not maintaining good personal hygiene.
- Being male
- Family history of the disease
- Being overweight or obese
- Trauma or constant irritation in the area
- Sedentary lifestyle or job
- A lot of body hair
- Poor personal hygiene
Testing for Pilonidal Cyst and Sinus
Pilonidal disease, a condition where small cysts or abscesses occur at the bottom of the tailbone, is typically diagnosed by a simple physical examination, and usually doesn’t require additional tests or imaging procedures. However, in certain cases where the diagnosis isn’t straightforward, imaging techniques might be employed. These could help distinguish the disease from other more serious conditions and assist in determining the extent of the disease, which is particularly helpful when planning surgical treatment.
One such technique uses a dye called methylene blue, which can help show the overall extent of pilonidal sinuses – unusually small, abnormal channels in the body. The dye is especially useful during surgery. According to one study, using methylene blue during surgery can decrease the chances of the disease returning in the long term by helping define what needs to be removed during the surgery. However, it is essential to be cautious because using methylene blue as an indicator for surgical removal might lead to not enough tissue being removed. This highlights a potential downside to using the dye.
Despite this, another study found that when operations were conducted using methylene blue, the amount of disease removed tended to be larger. This suggests the dye can help ensure complete removal of the disease. To make the dye easier to manage, it can be turned into a gel by adding a ointment called chloramphenicol.
In terms of other imaging techniques, ultrasound can be utilized to examine the extent of pilonidal disease. In one study pilonidal disease borders identified using ultrasound were consistent with those detected by physical touch most of the time. But in some cases, ultrasound was able to detect disease pockets that would have been missed by touch alone. Both external and endoanal (inside the anus) ultrasounds were found to be useful in assessing the disease’s extent and ruling out other possible conditions.
Lastly, MRI is a more expensive and time-consuming technique, but it could be useful when there’s a possibility of other issues like inflammatory bowel disease, fistulas (an abnormal connection between two body parts), pelvic infections, or cancerous growths. Some recent studies also suggest a role for a technique using a special dye known as indocyanine green, which can reveal the disease’s extent and assist in surgery.
Treatment Options for Pilonidal Cyst and Sinus
Pilonidal disease treatment usually involves surgery, especially in acute cases where an infection or abscess is present. However, treatment must be tailored to individual patients and should also take lifestyle changes and possible risk factors into account.
In the absence of an abscess, hair removal can be used as a primary or as an adjunct treatment because hair plays a significant role in pilonidal disease. The methods for hair removal include shaving, waxing, laser, or creams. Some studies have found that conservative treatment involving regular shaving and hygiene education can result in fewer surgeries.
Laser hair removal has been used in pilonidal disease but the results vary. Some studies found a reduced recurrence rate after surgery when laser hair removal was used. However, others suggest that hair removal might increase the rate of pilonidal recurrence after surgery.
A treatment called phenol, which is a liquid that hardens tissue, has also been used either as a main nonoperative treatment or in conjunction with surgery. Phenol can effectively manage pilonidal disease in some cases, as it can be easily given to patients in an outpatient setting and costs less than traditional surgical methods.
Fibrin and thrombin products – compounds that help to stop bleeding – have been used as primary treatments or in addition to surgical techniques for pilonidal disease. The use of fibrin glue, specifically, has demonstrated satisfactory patient results, and the majority of patients would recommend it for the treatment of pilonidal disease.
Platelet-rich plasma (PRP), a substance derived from a patient’s blood that assists in wound healing, has also been proposed as a possible treatment. The use of PRP has shown positive long-term results for managing pilonidal disease.
Another treatment method includes using hyperbaric oxygen, where the person breathes pure oxygen in a pressurized room or tube. This treatment is particularly helpful for wounds resulting from pilonidal disease surgeries because it assists in faster healing.
When it comes to surgical options for treating pilonidal disease, they range from pit picking, curettage, aspiration, unroofing, or surgical excision. Whether the wound from the surgery gets sutured or is allowed to heal by secondary intention is determined on a case-to-case basis. The vacuum-assisted closure system, a device that applies negative pressure to the wound, is sometimes used to hasten the healing process.
Antibiotics’ role in treating pilonidal disease is slightly controversial, but they may be used around the time of surgery, after surgery, or topically. However, this is not a widely agreed upon practice.
What else can Pilonidal Cyst and Sinus be?
Pilonidal disease is typically diagnosed by a healthcare provider based on the patient’s symptoms and a physical examination. If necessary, they might also use medical imaging to rule out other conditions that can cause similar symptoms. These could include:
- Abscesses (pockets of infected tissue)
- Hidradenitis suppurativa (a chronic skin condition)
- Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
- Anal fistula (an abnormal connection between the skin near the anus and the rectum)
- Epidural abscess (an infection in the area between the bones of the skull or spine and the membranes covering the brain or spinal cord)
- Other types of skin infections, like folliculitis, furuncles, or carbuncles
- Certain types of cancer
Pilonidal disease is most often found near the tailbone, but it can show up in other parts of the body too, such as the penis, scalp, abdomen, neck, groin, armpit, nose, vulva (the outer part of the female genitals), clitoris, and hand. It’s also been reported in people who work as barbers, hairdressers, or animal groomers. In some rare cases, pilonidal disease has been associated with a hand condition known as Dupuytren’s contracture, spinal conditions like ankylosing spondylitis, and conditions involving infection of the spine such as epidural abscesses and osteomyelitis.
Additionally, pilonidal disease has been linked with cases of tuberculosis, syphilis, and actinomycosis, all of which are infectious diseases that can mimic the symptoms of pilonidal disease.
Most of the time, tissue samples from pilonidal disease are sent for laboratory testing to confirm the diagnosis. This is because there have been rare cases where the condition turned out to be a type of cancer, such as squamous cell carcinoma, epidermoid carcinoma, basal cell carcinoma, or a condition called malignant degeneration. Because of this, it’s generally recommended that all samples be examined under a microscope as a precaution.
What to expect with Pilonidal Cyst and Sinus
The outlook for pilonidal disease (a condition where small cysts or abscesses occur in the cleft at the top of the buttocks) is generally very good. Although it’s a harmless disease, there have been some rare reports of it turning into skin cancer.
Pilonidal disease often comes back even after treatment, meaning some people might need to have the procedure more than once. However, with accurate diagnosis and changes in daily habits, the overall outlook remains very good.
Possible Complications When Diagnosed with Pilonidal Cyst and Sinus
Pilonidal disease mainly has two types of complications, namely the return of the disease and problems related to wound healing such as failure of the wound to close or infection at the site of the surgery. Initially, these complications might show up as a pocket filled with pus, or they might lead to another infection. Although uncommon, pilonidal disease has been linked with osteomyelitis, a serious infection of the bone, and the transformation of healthy cells into harmful malignant cells.
Common complications include:
- Reoccurrence of pilonidal disease
- Wound healing issues
- Wound breakdown (failure of wound to close)
- Infection at surgery site
- Initial presence as a pus-filled pocket (abscess)
- Secondary infections
- Osteomyelitis (bone infections) – rare
- Malignant transformation – rare
Preventing Pilonidal Cyst and Sinus
It’s important for patients to understand the risk factors associated with their condition. These can include being male, having a family history of the condition, being overweight or obese, experiencing trauma or irritation, living a sedentary or inactive lifestyle, having a lot of body hair, and not maintaining good hygiene.
Some of these risk factors can be changed to help manage the condition better. For example, losing weight, becoming more active, maintaining good personal hygiene, and managing body hair can all help. It’s always a good idea for patients to discuss these risk factors and any possible changes with their healthcare provider to ensure they’re taking the best steps towards managing their condition.
