INTRODUCTION — Pilonidal disease is a common condition of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks. While the natal cleft is the most common site of disease, other areas of the body such as the umbilicus and interdigital spaces can be affected. Management is variable and guided by the clinical presentation and extent of disease. The clinical manifestations, diagnosis, and management of pilonidal disease are presented here.
Pilonidal disease, especially when infected, can be confused with other conditions, which are discussed in other topics (see 'Differential diagnosis' below):
●(See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis".)
●(See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis".)
●(See "Perianal and perirectal abscess".)
ANATOMY — The natal cleft, also called the gluteal cleft, is the groove between the buttocks that extends from just below the sacrum to the perineum, superior to the anus (figure 1). The cleft or sulcus occurs as a result of the anchoring of the deep layers of the skin overlying the coccyx to the anococcygeal raphe. The cleft forms the border between the gluteus maximus muscles, which obscure the cleft when a person is upright (figure 2).
EPIDEMIOLOGY — The incidence of pilonidal disease is approximately 26 per 100,000 population, with a mean age at presentation of 19 years for women and 21 years for men, with men being affected two to four times more often than women [1-3]. Although pilonidal disease is less frequent in children and adults older than 45 years, it is still encountered in surgical practice in those age groups. Patient presentations are equally divided between acute and chronic disease; few patients present with asymptomatic disease [4].
RISK FACTORS — Risk factors for pilonidal disease include [1,3,5]:
●Overweight/obesity
●Local trauma or irritation
●Sedentary lifestyle or prolonged sitting
●Deep natal cleft
●Increased hair density in the natal cleft region
●Family history
●Characteristics of a person's hair [6]
●Polycystic ovary syndrome [7]
Although these are typical risk factors, often none are present in patients with pilonidal disease.
ETIOLOGY — Although pilonidal disease was originally thought to be congenital due to abnormal skin in the gluteal cleft [8], the contemporary theory considers it acquired rather than congenital [9-15]. The tendency of pilonidal disease to recur following an extensive surgical resection supports that theory.
The occasional occurrence of pilonidal cysts in locations other than the natal cleft (eg, umbilicus, scalp, interdigital spaces, and between breasts) also supports the acquired theory [14,16,17]. Others have reported pilonidal sinus occurring in locations that would be subject to local trauma from hair, such as on the hands of barbers, sheep shearers, and dog groomers [10-12].
PATHOGENESIS — The specific mechanism for the development of pilonidal disease is unclear, although the presence of hair and inflammation in the natal cleft are contributing factors [1,18,19]. As a person sits or bends, the natal cleft stretches, damaging or breaking hair follicles and opening a pore or "pit." The pores collect debris and serve as a fertile environment for hairs shed from the head, back, or buttocks to lodge and become embedded. As the skin is drawn taut over the natal cleft with movement, negative pressure is created in the subcutaneous space, drawing hairs deeper into the pore, and the friction causes the hairs to form a sinus.
Typically, pilonidal sinus tracts extend cephalad, which is likely related to the mechanical forces involved as the direction of the follicle determines the direction of the sinus tract; however, they can also extend laterally or inferiorly and may resemble anal fistula disease [1,18] (see 'Differential diagnosis' below). Cavities may contain hair, debris, and granulation tissue, but hair follicles are rarely identified on histopathologic examination [15]. Pilonidal cavities are not true cysts and lack a fully epithelialized lining; however, the sinus tracts may be epithelialized (figure 3). Foreign body giant cell reaction is typically associated with local cellular infiltrate.
Once the sinus becomes infected secondarily, an acute subcutaneous abscess develops, spreads along the tract, and may rupture spontaneously, discharging its contents through the skin cephalad or lateral to the natal cleft, or it may require operative drainage (figure 1). A recurring or chronic infection can also develop in the affected area due to retained hair or infected residue [1].
CLINICAL MANIFESTATIONS
Patient presentation — The patient presentation is highly variable, ranging from an asymptomatic pilonidal cavity or sinus to acute infection or chronic inflammation and drainage associated with an open wound of varying size [1,4]:
Acute — Symptoms of an acute exacerbation include sudden onset of mild-to-severe pain in the intergluteal region while sitting or performing activities that stretch the skin overlying the natal cleft (eg, bending, sit-ups). The patient may also report intermittent swelling as well as mucoid, purulent, and/or bloody drainage in the area. Fever and malaise are generally associated with an undrained abscess.
Chronic — Patients with chronic pilonidal disease experience recurrent or persistent drainage and pain. They may identify one or more areas of drainage (sinus tracts). There have been occasional case reports of squamous cell carcinomas arising in long-standing, neglected pilonidal sinuses [20]. Disease presenting with an unusual or aggressive appearance should be evaluated with a biopsy.
Physical examination — Pilonidal disease is identified by retracting the buttock cheeks enough to visualize the pores or sinuses within the valley of the natal cleft; additional findings may be present depending on the acuity of presentation:
●For asymptomatic patients, the physical examination reveals one or more primary pores (pits) in the midline of the natal cleft and/or a painless sinus opening cephalad and slightly lateral to the cleft (figure 1).
●For patients with acute exacerbation, the examination often reveals cellulitis in the natal cleft and a tender, fluctuant mass in or near the top of the natal cleft, usually slightly lateral to one side, indicating the presence of an abscess.
●For patients with chronic disease, one or more sinus openings draining mucoid, purulent, and/or bloody fluid can be identified (picture 1). A hair may occasionally be seen protruding from a sinus opening [1,4]. Secondary tracts or pits can be identified lateral to the midline in patients with complex disease.
DIAGNOSIS — Asymptomatic pilonidal disease is diagnosed clinically based upon findings of characteristic midline pores (pits) in the natal cleft region. Acute and chronic pilonidal disease can be diagnosed by additional findings of a tender mass and one or more sinus openings draining mucoid, purulent, or bloody fluid, respectively. The diagnosis is clinical; imaging or laboratory studies are not necessary.
DIFFERENTIAL DIAGNOSIS — Differentiating pilonidal disease from an alternative or concurrent disease often requires a thorough anorectal examination.
●Perianal abscess – A perianal abscess often presents with severe pain in the anal or rectal area, and constitutional symptoms such as fever and malaise are common (picture 2). On physical examination, an area of fluctuance or a patch of erythematous, indurated skin overlying the perianal skin may be noted. While perirectal abscesses are generally near the anus, pilonidal abscesses are located more cephalad in the natal cleft area (figure 1). (See "Perianal and perirectal abscess", section on 'Clinical manifestations'.)
●Anorectal fistula – An anorectal fistula is the chronic manifestation of an anorectal abscess. When the abscess ruptures or is drained, an epithelialized tract can form to connect the abscess in the anus or rectum with the perirectal skin. The diagnosis of a fistula is primarily based upon characteristic findings on history and physical examination: pain, purulent drainage, and a perirectal skin lesion. While anorectal fistulas track toward the anus, pilonidal sinuses track toward the cavity in the midline of the natal cleft (picture 3). (See "Anorectal fistula: Clinical manifestations, diagnosis, and management principles", section on 'Clinical features'.)
●Perianal complications of Crohn disease – Perianal complications of Crohn disease include anal fissures, fistulas, and abscesses. In particular, anal fissures may be asymptomatic or present with bleeding, deep ulceration (picture 4), or anal pain, which may be worsened during evacuation. Symptoms can vary from anal pain and purulent discharge to bleeding and incontinence. The area involved with perianal Crohn disease is generally centered around the anus, rather than the natal cleft area. (See "Perianal Crohn disease".)
●Buttock skin abscess, furuncle, carbuncle – Skin abscesses are collections of pus within the dermis and deeper skin tissues (picture 5). A furuncle is an infection of the hair follicle in which purulent material extends through the dermis into the subcutaneous tissue, where a small abscess forms. A carbuncle is a coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles. Furuncles and carbuncles commonly involve the buttocks (picture 6). These lesions are typically away from the midline and not associated with a sinus tract. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Skin abscess'.)
●Folliculitis – Folliculitis is a superficial bacterial infection of the hair follicles with purulent material in the epidermis. Folliculitis manifests as clusters of multiple small, raised, pruritic, erythematous lesions less than 5 mm in diameter (picture 7). Pustules may be present at the centers of the lesions. Folliculitis may present with sharply demarcated areas in the setting of Pseudomonas aeruginosa infection, reflecting exposure to areas of the skin in contact with contaminated water (picture 8). P. aeruginosa folliculitis may also manifest with larger lesions, up to 30 mm in diameter.
●Hidradenitis suppurativa – Hidradenitis suppurativa is a chronic follicular occlusive disease involving the intertriginous skin of the axillary, groin, perianal, perineal, and inframammary regions (picture 9 and picture 10). Hidradenitis suppurativa can occur in the perirectal area and present with purulent drainage. Hidradenitis suppurativa has some characteristics in common with pilonidal disease (eg, sinus tracts, sores), and some have postulated a relationship/common etiology between hidradenitis suppurativa and pilonidal disease [21,22]. However, hidradenitis is usually easily distinguished by its typical location in the perineal or inguinal area, rather than the natal cleft area. (See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis".)
●Systemic infection – In rare occasions, such as in immunocompromised hosts, systemic infectious processes such as tuberculosis, syphilis, and actinomycosis [23] can involve the intergluteal area and mimic pilonidal disease.
MANAGEMENT — The management of pilonidal disease is variable and depends upon the acuity of presentation and the extent of disease.
Asymptomatic disease — Based upon limited retrospective data, a surgical excision is not typically performed for patients who have never experienced an acute flare of a pilonidal sinus [24]. In a retrospective review of 26 patients with an incidental pilonidal sinus undergoing an excision and primary closure, the rate of healing following excision and primary closure was only 62 percent [24]. Because of the morbidity associated with most procedures performed to address pilonidal disease, surgery should be discouraged in the asymptomatic patient.
Although gluteal cleft hair has been implicated in the pathogenesis of pilonidal disease, it is not known whether gluteal cleft hair removal is beneficial to completely asymptomatic patients.
Acute abscess — An acute pilonidal abscess should be managed with prompt incision and drainage at the time of presentation. Antibiotics cannot be expected to be successful in treating a significant pilonidal abscess. Antibiotic use should be reserved for those with cellulitis in the absence of abscess or in those with an abscess and significant cellulitis after surgical drainage.
Surgical drainage — The incision is generally performed over the area of maximal fluctuance, and all inflammatory debris and visible hair within the abscess cavity should be debrided [1,25,26]. In a randomized trial, unroofing and curettage of the abscess cavity resulted in superior healing (96 versus 79 percent) and fewer recurrences (10 versus 54 percent) compared with drainage alone [27].
Wounds are packed with gauze, and healing occurs by secondary intention in the acute setting. Curettage of the pilonidal sinus and tract or excision of midline pores has no clinical benefit [28] and is not typically performed in the clinical setting of an acute infection [26].
Role of antibiotics — The role of antibiotics is generally limited to the clinical setting of cellulitis [1]. Antibiotic use should be reserved for those with cellulitis in the absence of abscess and for those with significant cellulitis after surgical drainage.
There are no definitive data to support antibiotic therapy in the management of the patient with an acute abscess or chronic pilonidal disease without cellulitis. A systemic review that included 25 randomized trials found a small postoperative healing benefit when perioperative antibiotics were given, but the magnitude of the benefit was modest, the sample sizes were small, and many studies had methodologic limitations [29].
However, patients with underlying immunosuppression, high risk for endocarditis, methicillin-resistant Staphylococcus aureus (MRSA), or concurrent systemic illness should be considered for ancillary antimicrobial prophylaxis in conjunction with surgical management [1]. Antimicrobial prophylaxis in high-risk clinical settings is reviewed separately. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures" and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections" and "Acute cellulitis and erysipelas in adults: Treatment".)
The most common organisms isolated in chronic pilonidal disease are aerobes, whereas anaerobes such as bacteroides predominate in abscesses. A reasonable antibiotic choice would be a first-generation cephalosporin (such as cefazolin) plus metronidazole. The management of cellulitis is reviewed separately. (See "Acute cellulitis and erysipelas in adults: Treatment".)
Follow-up care — Surgical drainage of an abscess may not be the final definitive treatment for pilonidal disease. Following simple incision and drainage for first-episode acute pilonidal abscesses, overall successful healing occurs in approximately 60 percent of patients; the remaining patients will require a second definitive procedure to address excess granulation before wound healing [30].
The recurrence rates reported in the literature ranged from 10 to 55 percent, with the presence of multiple pores and lateral sinus tracts corresponding with higher rates [26,30,31]. (See 'Chronic or recurrent disease' below.)
Following healing of a drained pilonidal abscess, patients should begin regular gluteal cleft shaving or another method of epilation (eg, laser, depilatory cream [eg, Nair]), as gluteal cleft hair has been implicated in the pathogenesis of pilonidal disease. Nonoperative strategies, including perineal hygiene, cleft hair control by either regular shaving or another method of epilation (eg, laser, depilatory cream [eg, Nair]), and observation for signs of an infection such as acute pain and drainage are optimal in this clinical setting [24,26]. In a retrospective study, meticulous hair control by natal cleft shaving, along with perineal hygiene and limited lateral drainage for abscesses, was credited with reducing hospital stay and total surgical operations compared with surgical alternatives [32]. By contrast, there is evidence that razor hair-shaving may increase the risk of recurrence following definitive surgery for pilonidal disease [33].
Chronic or recurrent disease — Chronic pilonidal disease presents with either recurrent abscesses with intervening periods of healing or one or more persistently draining sinuses that may be associated with a significant nonhealing wound. In either case, the definitive treatment is surgical [1]. However, the decision for surgery should be based on the severity of symptoms as perceived by the patient, rather than any arbitrary criterion such as the number of abscesses.
Surgical excision — The mainstay of operative management for chronic pilonidal disease is the destruction of all sinus tracts and skin pores (pits). Some surgeons prefer to excise all pilonidal sinus tracts down to the level of the sacrococcygeal fascia, while others only unroof and debride the tracts without excising them (figure 4). While the optimal technique is debated, there is agreement that normal tissue should be preserved as much as possible to facilitate wound management [1,26,34,35]. Higher volumes of excised tissue have been associated with increased complication and recurrence rates [36].
The value of using methylene blue to identify associated sinus tracts is debatable [1,34,35].
Alternative techniques to surgical excision are being developed but are not widely used:
●Video-assisted ablation of pilonidal sinus is a new minimally invasive treatment based on the complete removal of the sinus cavity through a minimal surgical wound [37]. In a small trial against conventional surgical excision, video-assisted ablation achieved fewer wound infections (1.3 versus 7.2 percent), less pain, quicker return to work (1.6 versus 8.2 days), and higher patient satisfaction [38]. This is a newer technique that has not seen wide adoption. Further research is needed to determine its value in the treatment of pilonidal disease.
●Phenol injection has been used in lieu of surgical excision in selected patients with chronic pilonidal disease. Crystallized phenol solution can be injected into the sinus tract after hairs and debris have been removed as an outpatient procedure. Along with gluteal cleft hair control, one or more applications of phenol had success rates ranging from 60 to 95 percent and few recurrences [39-41]. It has been used in combination with pit excision [42].
●Fibrin glue has been used either as a monotherapy to fill the sinus tract or as an adjunct to surgery to seal the excision bed. However, a Cochrane review failed to find sufficient evidence for its benefit because the studies were small and at high risk of bias [43].
Wound management — Various surgical procedures differ primarily in subsequent wound management following excision and are named accordingly. All named procedures for pilonidal disease can be performed following either unroofing or complete excision of the pilonidal sinuses, with the exception of Bascom's pit pick operation, which does not involve radical excision [44].
Options — Options of wound management following pilonidal sinus excision generally fall under one of two categories:
●Delayed wound closure – Delayed closure approaches include leaving the wound open or marsupialization of the skin edges to the sacrococcygeal fascia (figure 5). The wounds can be treated by dressing changes until healed by secondary intention. In a single-surgeon series of over 500 patients treated by minimal, but complete, surgical excision, followed by healing by secondary intention using moist dressings, only 3.2 percent had persistent or recurrent disease requiring reoperation, most often due to poor compliance with wound care [45]. (See "Basic principles of wound management", section on 'Wound packing'.)
An alternative method for managing the open wound is the use of negative pressure wound therapy (NPWT), which is perhaps more useful for larger defects. A trial that randomly assigned 49 patients to standard care or NPWT found a slightly improved time to complete wound healing for NPWT compared with standard therapy (84 versus 93 days) [46]. There were no differences in visual analog pain scores or recurrence rates between the groups. Practical issues with the application of the dressing and device may limit its use in this setting. Negative pressure wound therapy is discussed in detail elsewhere. (See "Negative pressure wound therapy".)
●Primary wound closure – Primary wound closure can be accomplished by either midline (figure 6) or off-midline techniques (figure 7) [47,48]:
•Midline primary closure involves simply reapproximating the cut edges of the skin and subcutaneous tissue at the midline with several layers of sutures.
•Off-midline primary closure takes more planning. The initial incision is typically made at a location lateral to the midline, which depends on the planned technique. Following excision or unroofing of the pilonidal sinus tracts, a skin and subcutaneous tissue flap is usually raised to cover the midline defect. The incision is then closed off the midline with several layers of sutures. Off-midline closure is technically more demanding but can cover a wider defect and result in lower tension at the closure. Techniques commonly used to ensure an off-midline closure are discussed below [49]. (See 'Techniques of flap-based procedures' below.)
While an off-midline approach to primary closure may be preferred, the optimal procedure has not been identified, despite multiple randomized trials [50,51]. As such, surgeons should choose a technique based on the extent of the resection, presence or absence of infection, and their experience and preference [26,47,52].
Flap-based reconstructive options allow for excision of greater amounts of involved tissue and are associated with a decrease in tension in the healing wound. In addition, these techniques facilitate wound closure lateral to the natal cleft, an area characteristically moist, hypoxic, and bacteria laden [53-55]. Rhomboid, V-Y, and other rotational flap reconstructions are typically reserved for patients with extensive disease or those who have failed simpler operations (eg, excision and sutured midline closure) [2]. The Karydakis flap and Bascom's cleft-lift procedure can be used for initial surgical management or for recurrent disease presenting with anatomy favorable to those procedures. (See 'Techniques of flap-based procedures' below.)
Evidence — Numerous studies have compared various techniques of wound management following pilonidal sinus excision, from which the following trends emerged:
Primary versus delayed closure — A primary closure is associated with faster wound healing (complete epithelialization) and a sooner return to work, but a delayed (open) closure is associated with a lower likelihood of pilonidal disease recurrence. This is best illustrated by a meta-analysis of 26 randomized trials including 2530 patients [47]:
●Time to wound healing – Thirteen trials (n = 1421 patients) included data for time to wound healing, but data were not aggregated due to high statistical heterogeneity. Nine trials reported faster mean/median time to wound healing with a primary closure, and four studies reported similar results without reporting statistical tests. The largest study included 380 patients and found that patients undergoing a primary repair had a significantly faster rate of wound healing compared with patients with open wounds (14.5 versus 60.4 days) [56].
●Time to return to work – Eleven trials (n = 1729 patients) included data for time to return to work, but data were not aggregated due to high statistical heterogeneity. Nine studies reported faster time to return to work following a primary closure. The largest study included 144 patients and found that patients undergoing a primary repair had a significantly faster rate of return to work compared with patients with open wounds (11.9 versus 17.5 days) [57]. The remaining two studies utilized marsupialization as the technique for delayed wound closure; patients undergoing primary closure returned to work later than patients treated with the marsupialization (21 versus 3 days [52] and 17.9 versus 11.2 days) [58].
●Recurrence rate – Based upon 16 trials that included 1666 patients, the overall recurrence rate of pilonidal disease was 6.9 percent. Primary wound closure was associated with a significantly higher recurrence rate compared with a delayed wound closure (8.7 versus 5.3 percent, relative risk [RR] 1.5, 95% CI 1.08-2.17).
●Rate of surgical site infections – Overall, surgical site infections (SSIs) were low in most trials. Based upon 10 trials that included 1231 patients, there was no significant difference between primary and delayed closure and risk of SSI (8 versus 10 percent, RR 0.76, 95% CI 0.54-1.08).
Off-midline versus midline primary sutured closures — For patients undergoing a primary wound closure, off-midline (lateral) closure techniques have been associated with lower complication rates, healing time, and recurrence rates compared with simple midline closure techniques. The same meta-analysis discussed above also showed that [47]:
●Sutured off-midline wounds took significantly less time to heal compared with sutured midline wounds (n = 100 patients, mean difference 5.4 days, 95% CI 2.3-8.5 days).
●The risk of SSI was significantly lower for sutured off-midline wounds (n = 541 patients, RR 0.27, 95% CI 0.13-0.54).
●The risk of pilonidal disease recurrence was significantly lower for sutured off-midline wounds (n = 574 patients, RR 0.22, 95% CI 0.11-0.43).
●The overall complication rate was significantly lower for sutured off-midline wounds (n = 461, RR 0.23, 95% CI 0.08-0.66).
A meta-analysis focused on recurrence included 15 studies with a minimum follow-up of five years (range 58 to 240 months) [59]. The overall incidence of recurrence was 13.8 percent. Delayed (open) closure, midline, and off-midline primary sutured closures were associated with a recurrence rate of 17.9, 16.8, and 10 percent, respectively, making the off-midline closure the preferred technique. It should be noted that this meta-analysis was inconsistent with the Cochrane meta-analysis cited above, in which delayed closure was associated with a lower recurrence rate than primary repair (8.7 versus 5.3 percent, RR 1.5, 95% CI 1.08-2.17) [47]. This discrepancy may be due to different lengths of follow-up, which is also reflected in the absolute recurrence rates.
Techniques of flap-based procedures
Rhomboid (Limberg) flap (with video) — The rhomboid or Limberg flap is a rotational fasciocutaneous flap that permits primary off-midline closure of the wound and flattening of the gluteal cleft (figure 8) [60]. Here is a sample video of this technique (movie 1). Here are two photos of completed rhomboid flaps (picture 11 and picture 12).
The reported recurrence rate (0 to 6 percent) and surgical infection rate (0 to 6 percent) are both low and compare favorably to those of simple midline closure in some studies [61-63].
Karydakis flap — The Karydakis flap uses a mobilized fasciocutaneous flap secured to the sacrococcygeal fascia with lateral sutures to achieve an off-midline wound closure (figure 9) [64]. It achieves a recurrence rate of <5 percent and a wound complication rate of 7 to 21 percent, depending on studies [65-67].
Bascom's cleft-lift procedure (with video) — This technique also creates a flap-based closure off the midline, which obliterates the cleft [68]. The primary healing rates were 80 to 96 percent, and the recurrence rate was 0 to 17 percent [53,69-71]. Here is a sample video of this procedure (movie 2).
A meta-analysis of six randomized trials comparing Karydakis/Bascom procedures with the Limberg procedure found no difference in recurrence or wound complications rate [72].
V-Y advancement flap — A V-Y advancement flap is another technique of excising pilonidal disease and closing the wound defect (figure 10). Healing rates of >90 percent and low recurrence rates have been reported in case series [73,74].
Z-plasty — Pilonidal sinuses can be excised and the defect reconstructed using a standard Z-plasty (figure 11 and figure 12). Here is a photo of pilonidal disease successfully treated with Z-plasty (picture 13). The rationale and technique of Z-plasty is discussed elsewhere. (See "Z-plasty" and "Overview of flaps for soft tissue reconstruction", section on 'Introduction'.)
Drain — For patients who have primary wound closure, a drain may be used on a case-by-case basis at the surgeon's discretion. Drains have been shown to reduce the incidence of wound complications such as fluid collections but not impact wound infection or recurrence rates [65,75,76]. Drain use should likely be based on the size of the flap utilized and the amount of potential dead space left after reconstruction. Drain removal is based upon surgeon judgment but can often be done after drains produce 20 mL or less for two consecutive days.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Pilonidal cyst (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Pilonidal disease is a condition involving the skin and subcutaneous tissue at or near the upper part of the natal cleft between the buttocks. It is most commonly seen in patients in their late teens and early twenties, with a male predominance. It is less frequently seen in children and in those older than 45 years. (See 'Introduction' above and 'Anatomy' above and 'Epidemiology' above.)
●Etiologies and risk factors – Pilonidal disease is an acquired condition likely related to the mechanical forces on the skin overlying the natal cleft damaging or breaking hair follicles and opening pores that collect loose hairs and debris. Subsequent infection of the pores leads to abscess and/or draining sinus formation and symptoms. Risk factors include obesity, deep natal cleft, prolonged sitting, local trauma, and family history. (See 'Risk factors' above and 'Etiology' above and 'Pathogenesis' above.)
●Clinical presentation and diagnosis – The clinical presentation is highly variable, ranging from an asymptomatic pilonidal sinus to an acute infection or chronic exacerbation with inflammation and drainage. The physical findings include one or more primary pores (pits) in the midline of the natal cleft with or without a painless sinus opening(s) cephalad and slightly lateral to one side (figure 1). For patients with acute or chronic disease, a tender mass or sinus draining mucoid, purulent, and/or bloody fluid can be identified. Diagnosis is clinical without the need for laboratory or imaging studies. (See 'Clinical manifestations' above and 'Diagnosis' above.)
●Treatment – Patients who have a pilonidal sinus but have never experienced an acute flare do not require surgery. (See 'Asymptomatic disease' above.)
•Acute infection – An acute pilonidal abscess is managed with prompt incision and drainage at the time of presentation. The wound should be debrided of all visible hair and inflammatory debris. Antibiotics should be reserved for patients with cellulitis in the absence of abscess and for those with significant cellulitis after surgical drainage. Additionally, patients with underlying immunosuppression, high risk for endocarditis, methicillin-resistant Staphylococcus aureus (MRSA), or concurrent systemic illness may require antibiotics in conjunction with surgical drainage. (See 'Acute abscess' above.)
Following healing of a drained pilonidal abscess, patients should begin regular gluteal cleft shaving or another method of epilation (eg, laser, depilatory cream [eg, Nair]) as gluteal cleft hair has been implicated in the pathogenesis of pilonidal disease. By contrast, there is evidence that razor hair-shaving may increase the risk of recurrence following definitive surgery for pilonidal disease, and it is not known whether gluteal cleft hair removal is beneficial to completely asymptomatic patients. (See 'Follow-up care' above.)
•Chronic disease – Chronic pilonidal disease may require surgical excision. The decision for surgery should be based on the severity of symptoms as perceived by the patient, rather than any arbitrary criterion such as the number of abscesses. (See 'Chronic or recurrent disease' above.)
The mainstay of operative management for chronic pilonidal disease is destruction of all sinus tracts and skin pores (pits). Some surgeons prefer to excise pilonidal sinus tracts down to the level of the sacrococcygeal fascia, while others only unroof and debride the tracts without excising them. There is consensus that normal tissue should be preserved as much as possible to facilitate wound management. (See 'Chronic or recurrent disease' above.)
●Surgical approaches – Various surgical procedures differ primarily in subsequent wound management following excision and are named accordingly; options include delayed wound closure (leaving the wound open or marsupialization) and primary wound closure (midline closure or off-midline [lateral] closure). Although one technique has not been conclusively shown to be superior to others, the preponderance of evidence suggests:
•A primary closure is associated with faster wound healing (complete epithelialization) and a sooner return to work, but a delayed (open) closure is associated with a lower likelihood of pilonidal disease recurrence. The choice should be individualized based on the extensiveness of the resection, presence/absence of infection, and surgeon experience/preference.
•Off-midline closures reduce complication rate, healing time, and recurrence rate compared with midline closure. Thus, for wounds undergoing a primary closure, we recommend an off-midline (lateral) closure rather than a midline closure (Grade 1B).
•Flap-based reconstructive options allow for excision of greater amounts of involved tissue and are associated with a decrease in tension in the healing wound. In addition, these techniques facilitate wound closure lateral to the natal cleft, an area characteristically moist, hypoxic, and bacteria laden. Rhomboid, V-Y, and other rotational flap reconstructions are typically reserved for patients with extensive disease or those who have failed simpler operations (eg, excision and sutured midline closure) [2]. The Karydakis flap and Bascom's cleft-lift procedure can be used for initial surgical management or for recurrent disease presenting with anatomy favorable to those procedures. (See 'Techniques of flap-based procedures' above.)
