Non-Healing Pressure Ulcer or Pilonidal Sinus?

Shanojan Thiyagalingam MD, Ali Ahmad MD, Karun Badwal MD, Anupam Chandra MD
Mayo Clinic

Introduction
New or worsening changes in skin integrity and pressure ulcers are a reportable quality measure in skilled nursing
facilities (SNF). Their management requires comprehensive evaluation for predisposing and precipitating factors and
comorbidities that may impede healing. A thorough history and clinical examination is an essential first step in this
process.

Case
An 84-year-old gentleman with a past medical history of end stage renal failure on hemodialysis, peripheral arterial
disease, peripheral neuropathy, hypothyroidism and chronic low back pain, was seen in subacute rehabilitation center
after being hospitalized for pneumonitis. Admission evaluation at the SNF revealed prior report of a stage 2 sacral
decubitus ulcer for the past 5 years. Upon the admission physical examination, there was a 2 cm region of
hyperpigmented skin with a central sinus without fluid drainage just superior to the natal cleft, consistent with pilonidal
sinus. On further questioning, the patient reported intermittent pain and drainage from this area since he was in his
early 20s. There was no other skin breakdown in the sacral region. He was not a surgical candidate. Given overall
frailty and comorbid conditions he was at high risk for pressure ulcers and due to the presence of the pilonidal sinus
he was at risk of local infections, hence, precautions such as frequent repositioning and hydrocolloid dressing were
instituted.

Discussion
Pilonidal sinus is a tunnel in the skin and subcutaneous tissue at or near the upper part of the natal cleft. It contains
hair and debris which may get infected leading to recurrent drainage, pain and abscesses. Diagnosis is clinical
without need for imaging or lab tests. Recurrent disease requires surgical intervention. Though pressure ulcers occur
frequently in this location, the pathophysiology and management of pressure ulcer differs from this. This case
highlights the importance of thorough history and examination in evaluation of recurrent and non-healing pressure
ulcers.