Pilonidal Disease

Pilonidal disease was first reported in 1833. Sacrococcygeal pilonidal sinus is a common disorder among young adults. It is observed most commonly in people aged 15-30 years, occurring after puberty when sex hormones are known to affect the pilosebaceous gland and change healthy body hair growth. The onset of pilonidal disease is rare in people older than 40 years.
History of the Procedure

In the 1950s, pilonidal sinus disease was thought to be of congenital origin rather than an acquired disorder. The pilonidal sinus and abscess were thought to be secondary to a congenital remnant of an epithelial-lined tract from postcoccygeal epidermal cell rests or vestigial scent cells. Sinuses to the neural canal can occasionally extend to the dura, but these are rare and are located in the lumbar region rather than the sacral region. Pilonidal disease is now widely accepted as an acquired disorder based on the observations that congenital tracts do not contain hair and are lined by cuboidal epithelium. The recurrence of the disorder after complete excision of the disease tissue down to the sacrococcygeal fascia and the high incidence of chronic pilonidal sinus disease in patients who are hirsute further support an acquired theory of pathogenesis.
Problem

In a recent census and survey of patients admitted to England hospitals in 1985 for treatment of pilonidal sinus disease, 7000 patients required hospitalization for an average of 5 days. The hospitalization of these patients for the treatment of pilonidal disease resulted in a loss of productivity, a loss of earnings, and a disruption of education because patients recovered in the hospital.

Treatment options are now available that provide a rapid rate of cure, a lower recurrence rate, and a minimized number of hospital admissions. Although numerous randomized clinical studies have evaluated different treatments, no clear consensus has been reached as to the optimal medical or surgical treatment.
Frequency

The incidence rate of pilonidal disease is approximately 0.7%. Men are affected 2.2-4 times more frequently than women. During a population study involving college students, the incidence rate was found to be 1.1% (365 of 31,497 people) in males and 0.11% (24 of 21,367 people) in females. The onset of the disease is earlier in women, which may be due to earlier puberty in women.
Etiology

The incidence is also affected by hair characteristics such as kinking, medullation, coarseness, and growth rate. White persons are affected more frequently than African or Asian persons. Other factors affecting the incidence are increased sweating activity associated with sitting and buttock friction, poor personal hygiene, obesity, and local trauma, which help to explain why pilonidal sinus disease is common in army recruits. In an article examining pilonidal sinus in Turkish soldiers, the incidence was found to be 8.8%, with the correlation factors known to be family history, obesity, being the driver of a vehicle, and the presence of folliculitis or a furuncle at another site on the body.
Pathophysiology

After the onset of puberty, sex hormones affect the pilosebaceous glands, and, subsequently, the hair follicle becomes distended with keratin. As a result, a folliculitis is created, which produces edema and follicle occlusion. The infected follicle extends and ruptures into the subcutaneous tissue, forming a pilonidal abscess. This results in a sinus tract that leads to a deep subcutaneous cavity. The direction of the sinus tract is cephalad in 90% of the cases, which coincides with the directional growth of the hair follicle. This usually places the tracking follicle approximately 5-8 cm from the anus. In the more rare instance that the sinus is located caudally, it is usually found 4-5 cm from the anus. The laterally communicating sinus overlying the sacrum is created as the pilonidal abscess spontaneously drains to the skin surface. The original sinus tract from the natal cleft becomes an epithelialized tube. The laterally draining tract becomes a granulating sinus tract opening.

Loose hairs are drilled, propelled, and sucked into the pilonidal sinus by friction and movement of the buttocks whenever a patient stands or sits. Hair enters tip first, and the barbs on the hair prevent it from being expelled so that the hair becomes entrapped. Physical examination occasionally may reveal a tuft of hair emerging from the midline opening in the natal cleft. This trapped hair stimulates a foreign body reaction and infection. Rarely, foreign bodies other than human hair can cause this disease process. Rare case reports exist in which the hair did not come from the patient but, instead, from a bird's feather, the type used to stuff feather bedding.
Clinical

Although pilonidal disease may manifest as an abscess, pilonidal sinus, recurrent or chronic pilonidal sinus, or a perianal pilonidal sinus, the most common manifestation of pilonidal disease is a painful fluctuant mass in the sacrococcygeal region. Initially, 50% of patients first present with a pilonidal abscess that is cephalad to the hair follicle and sinus infection. Pain and purulent discharge from the sinus tract are present 70-80% of the time and are the 2 most frequently described symptoms. In the early stages prior to the development of an abscess, only a cellulitis or folliculitis is present. The abscess is formed when a folliculitis expands into the subcutaneous tissue or when a preexisting foreign body granuloma becomes infected. The subcutaneous cavity and laterally oriented secondary sinus tract openings are lined with granulation tissue, whereas only the midline natal cleft pit sinus is lined by epithelium.

The diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, which can be palpated as an area of deep induration beneath the skin in the sacral region. These tracts most commonly run in the cephalad direction. When the tract runs in the caudal direction, perianal sepsis may be present. The distinctions among pilonidal disease, fistula-in-ano, and hidradenitis can be difficult to discern. In the differential diagnosis, also include skin furuncle, syphilitic granuloma, tubercular granuloma, and osteomyelitis of the underlying sacrum with a draining sinus.

Recurrent pilonidal disease is observed most commonly after the incision and drainage of a pilonidal abscess. In this setting, the pilonidal sinus has not been excised and is still present after the abscess cavity heals, only to precipitate a recurrence. After surgical excision, the hair follicle has been removed and is no longer the pathogenic precipitating cause of the chronic pilonidal sinus. Instead, the base of the unhealed surgical wound is believed to become filled with granulation tissue, hair, and skin debris, which is a nidus for the ongoing foreign body reaction that takes place to create the chronic disease. This theory, coupled with the known predisposing intergluteal anatomy that draws hair into the pilonidal sinus cavity or surgical wound, is thought to precipitate the extensive recurrent and chronic disease.

Endoanal pilonidal sinus is a rare variety of pilonidal disease that affects the perianal skin directly or may occur circumferentially around the anus, involving the skin of the anal verge. Three causes of perianal pilonidal disease have been described. First, the pilonidal sinus may tract down caudally, creating a perianal fissure or fistula communicating with the anal canal. Second, hair may enter the healing wound of a surgically managed fistula-in-ano. Third, hair may be propelled and penetrate the normal anoderm and produce a similar foreign body reaction, which is usually observed in the sacrococcygeal region.

Pilonidal Cyst Overview

A pilonidal cyst is a cyst at the bottom of the tailbone (coccyx) that can become infected and filled with pus. Once infected, the technical term is pilonidal abscess. Pilonidal abscesses look like a large pimple at the bottom of the tailbone, just above the crack of the buttocks. It is more common in men than in women. It usually happens in young people up into the fourth decade of life.

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