Pilonidal Cyst

Pilonidal cyst treatment requires removal and drainage.

• A pilonidal cyst is a cystic structure that develops along the tailbone (coccyx) near the cleft of the buttocks, approximately 4 cm-5 cm from the anus.
• These cysts usually contain hair and skin debris. Individuals with a pilonidal cyst may not have any symptoms at all (termed asymptomatic), whereas others may develop an infection of the cyst with associated pain and inflammation.
• The treatment and management of pilonidal cysts depend on many factors, including the extent and chronicity of the disease. Recurrence of pilonidal cysts is common.
• Pilonidal cysts were first described in 1833 by Herbert Mayo. The term pilonidal is derived from the Latin words "pilus" (hair) and "nidus" (nest) and was coined in 1880 by R.M. Hodge.
• Pilonidal cysts occur more frequently in men than in women, and they are more common in Caucasians than in other racial groups.
• Pilonidal cysts usually occur between the ages of 15 to 24, and their development is uncommon after the age of 40.

Although there are several theories as to the causes and origins of pilonidal disease, most researchers today believe that pilonidal cysts are acquired (rather than congenital, or inborn) and that they are caused by the penetration of loose hairs into the skin through dilated hair follicles into the subcutaneous tissues. In response to this ingrown hair, a local inflammatory reaction causes a cystic structure to form around the hair and the other skin debris. Excessive pressure or repetitive trauma to the sacrococcygeal area are thought to predispose individuals to develop the cyst or to irritate an already existing pilonidal cyst.

During World War II, more than 80,000 U.S. soldiers developed pilonidal cysts requiring hospitalization. Because so many of the afflicted servicemen rode in bumpy Jeeps for prolonged periods of time, the condition was termed "Jeep disease." It was during this time that many investigators produced articles on the treatment and management of pilonidal disease.

In addition to male gender, other risk factors for the development of pilonidal cysts include a family history of pilonidal cysts, occupations which require prolonged sitting, hirsute (hairy or having copious hair) individuals, and the presence of a deep natal cleft (the cleft between the buttocks). Obese individuals are more likely to experience a recurrence of pilonidal cysts.

As previously mentioned, some individuals with a pilonidal cyst may be asymptomatic, and the only finding may be a dimple or an opening in the skin (sinus tract) in the sacrococcygeal area. However, if the pilonidal cyst becomes infected, the following signs and symptoms may develop:

• Pain over the lower spine
• Redness of the skin
• Warmth of the skin
• Localized swelling over the lower spine
• Drainage of pus from an opening in the skin (sinus tract) over the lower spine
• Fever (uncommon)

Less commonly, pilonidal cysts can develop in other areas of the body such as the hands.

A pilonidal cyst can be diagnosed on the basis of the characteristic symptoms and the findings on the physical exam. In general, blood work or imaging studies are usually not necessary to initially make the diagnosis.

Individuals who simply have a dimple or sinus tract that has not become infected or inflamed do not generally require any immediate treatment. However, an infected pilonidal cyst may become a pilonidal abscess (pus containing structure) that requires incision and drainage (lancing) in order to improve. This procedure can generally be performed in a physician's office or in the emergency department.

• This is done by numbing the area with a local anesthetic and making an incision with a scalpel over the infected area to open the abscess cavity.
• The pus is drained, and any accumulated hair and debris are removed. The wound is cleaned with saline solution, packed with gauze, and covered with a bandage.
• Antibiotics are generally not necessary unless signs of a spreading skin infection (cellulitis) are present. Pain medication will often be prescribed.

A follow-up with your physician in one to two days should be arranged to ensure adequate wound healing and to monitor for any potential complications. The wound packing will be removed by your physician, the wound will be examined, and repacking of the wound may be required if there is still purulent drainage. Treatment at home will consist of medications for pain control and diligent wound care. Sitz baths can be taken at home with warm water once the packing has been removed, and the skin wound will generally heal and close on its own in about four weeks. Keeping the wound area clean and removing any hair from around the sacrococcygeal area can help to prevent recurrence.

For those individuals with recurrent, complicated, or chronic pilonidal disease, more invasive surgery to excise the sinus or cysts may be necessary in a hospital operating room. Several different surgical procedures may be used in this case, and your surgeon will discuss the various options with you. In general, the major difference between the various surgical interventions centers around leaving the surgical wound open after surgery and allowing it to heal on its own, versus closure of the surgical wound after debridement during the surgery itself. Recovery time after surgery can take several weeks, and recurrence rates may vary depending on the choice of the surgical procedure. Potential postsurgical complications may include wound infection, poor wound healing, or recurrence.

The treatment of pilonidal disease using phenol injections is another alternative to surgery alone, although this option is more commonly employed in Europe than in the United States. Continued outpatient care and follow-up with your surgeon is necessary to ensure proper wound healing and to manage any potential complications or recurrence of pilonidal disease.

The complications of a pilonidal cyst may include the following:

• Abscess formation
• Recurrence of the pilonidal cyst
• Systemic infection (infection that spreads throughout the body)
• Rarely, squamous cell carcinoma (the development of a form of skin cancer within the cyst)

Good hygiene in the sacrococcygeal area is critical. Keep the area clean and dry, and either shave or use depilatory creams to keep the area free of hair. Electrolysis or laser hair removal in this area may be another option. Also, try to avoid prolonged sitting or excessive repetitive pressure to the area of the coccyx (tailbone). Weight loss in obese individuals may also help decrease the likelihood of recurrence.

Although some patients may experience recurrence of pilonidal disease, in general the long-term prognosis is excellent. In the rare case of squamous cell carcinoma development, prognosis will vary according to different factors and should be discussed with your doctor. Mortality (death) from pilonidal disease is extremely rare.