11/1/2017 Pilonidal cyst – Knowledge for medical students and physicians

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Clinical science

Pilonidal cyst (Intergluteal pilonidal disease)

Abstract
A pilonidal cyst (intergluteal pilonidal disease) is a skin condition caused by local inflammation of the superior
midline gluteal cleft, which may progress to a local abscess or fistula. It is currently hypothesized to be an
acquired condition with local penetration of hair follicles and debris in stretched intergluteal pores. Affected
individuals – typically obese, sedentary men with excessive body hair and a deep gluteal cleft – may be
asymptomatic or present with mild local symptoms such as local oozing or erythema; however, abscesses can
also cause severe pain. Pilonidal cysts are diagnosed based on patient history and clinical examination. To treat
the condition, radical resection with secondary wound healing is usually necessary. Asymptomatic patients can
be treated conservatively.

Epidemiology
Sex: ♂ > ♀ (∼ 3:1)Prevalence: 26/100,000 in the United States
Peak incidence: 15–25 years

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiology
The exact mechanism is unknown, however, the current prevailing hypothesis is that pilonidal disease is an
acquired condition.

Sitting or bending cause hair follicles, in vulnerable skin within a deep natal cleft, to stretch and break →
formation of an open pore or pit. These open pores either collect debris or broken hair roots (from the
head, back or buttocks).
Movement causes negative pressure (e.g., “suction effect”) and further penetration of hair into local
subcutaneous tissue → formation of a pilonidal sinus

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11/1/2017 Pilonidal cyst – Knowledge for medical students and physicians

These collections trigger local tissue inflammation within the pilonidal sinus → acute infection (abscess)
or fistulae

References:[1][3][4][5][6][7]

Risk factors
Young men with excessive body hair
Obesity
Deep gluteal cleft
Poor anal hygiene/local irritation
Sedentary lifestyle
Family history

References:[8][7]

Clinical features
General features
Possible history of trauma or surgery for pilonidal cyst
May be asymptomatic
Simple sinus tract opening in sacrococcygeal region, ∼ 5 cm from the anal verge
Acute inflammation (e.g., abscess)
Possible purulent discharge and fever
Can be very painful
Fluctuant, erythematous swelling
Chronic inflammation
Discharge (purulent, mucoid, or blood‑stained) from abscess or fistula opening
Localized pain in sacrococcygeal region or at fistula opening

References:[1][4]

Differential diagnoses
Anal fistula (e.g., due to Crohn's disease)
Hidradenitis suppurativa
Anorectal abscess
Sacrococcygeal teratoma
Granulomas (e.g., syphilis, tuberculosis)

References:[4]

The differential diagnoses listed here are not exhaustive.

Treatment
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11/1/2017 Pilonidal cyst – Knowledge for medical students and physicians

Conservative treatment
Indications
Asymptomatic patients
Postsurgical care of symptomatic patients
Approach
Improved local hygiene
Local hair control (e.g., laser epilation)
Observation for signs of infection

Surgical treatment
Indication: Symptomatic patients
Procedures
Acute pilonidal cyst: incision and drainage, with secondary wound closure
Chronic or recurrent pilonidal cyst: surgical resection
Closure may proceed in two ways:
Primary wound closure
Secondary wound closure
Possible marsupialization, with adequate sterile packing
Negative pressure wound therapy (NPWT)
Tract curettage or excision with fibrin glue as a sealant

References:[4][7][9][10][11][12]

Tips & Links

Iain J D McCallum et al., Healing by primary closure versus open healing after surgery for pilonidal sinus:
systematic review and meta-analysis

Sources

[1] Sullivan DJ, Brooks DC, Breen E, Berman RS, Chen W, Intergluteal pilonidal disease: Clinical
last updated 10/25/2017
manifestations and diagnosis, UpToDate
AMBOSS - Medical Knowledge Distilled
[2] Majeski J, Stroud J, Sacrococcygeal Pilonidal Disease
Prepare[3]and succeed
Bailey HR,on your medical
Billingham exams MJ, Snyder MJ, Colorectal surgery, Elsevier Saunders
RP, Stamos
[4] Koyfman A, Long BJ, Shlamovitz GZ, Pilonidal Cyst and Sinus, WebMD
[5] Goel TC, Goel A, Practical Surgery Short Clinical Cases, Jaypee Brothers Medical Publishers
[6] Miller D, Harding K, Pilonidal sinus disease, World Wide Wounds
[7] Riojas RA, Layton BD, Schraga ED, Pilonidal Cystectomy, WebMD
[8] Authors:Phillip L Rice, Jr, MDDennis P Orgill, MD, PhDSection Editor:Marc G Jeschke, MD,
PhDDeputy Editor:Kathryn A Collins, MD, PhD, FACS, Classification of burns, UpToDate
[9] Ghnnam WM, Hafez DM, Laser Hair Removal as Adjunct to Surgery for Pilonidal Sinus: Our Initial
Experience
[10] Sullivan DJ, Brooks DC, Breen E, Berman RS, Weiser M, Chen W, Management of intergluteal
pilonidal disease, UpToDate
[11] Greenberg R, Kashtan H, Skornik Y, Werbin N, Treatment of pilonidal sinus disease using fibrin glue
as a sealant, Techniques in Coloproctology
[12] Steele SR, Perry WB, Mills S, Buie WD, Practice Parameters for the Management of Pilonidal
Disease, American Society of Colon and Rectal Surgeons

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