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 and less frequently seen in children and in those older than 45 years.
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.
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.
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.
Patients who have a pilonidal sinus but have never experienced an acute flare do not require surgery.
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.
Following healing of a drained pilonidal abscess, patients should begin regular gluteal cleft shaving or another method of epilation as gluteal cleft hair has been implicated in the pathogenesis of pilonidal 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.
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
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
•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). 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.