Histopathology of

Pilonidal Sinus
Dr. Rawa Muhsin Ali
MBChB, ABHS-APath

The Ninth Fast Track Review

Contents
• Overview
• Pathogenesis
• Histology
• Role of pathology
• Differentials
• Malignancy
• Should we examine?
Pilonidal Sinus

pilus = hair nidus = nest sinus = pocket

Overview
• Incidence of 26 per 100,000 population
• Male: female ratio 2-4:1
• Mean age 20
• Most common site is natal cleft
• Risk factors include obesity, prolonged sitting, trauma,
deep cleft, increased hair density, PCOS
Pathogenesis
• Acquired is favored over congenital
• Gender disparity and onset in adolescence
• Association with occupation (Jeep drivers and
barbers’ hands)
• Similar lesions in other body sites
• Lack of skin appendages and lining epithelium in wall
of sinus despite presence of hair shafts deeply
embedded
• Lack of success of surgical methods
Pathogenesis
• Bascom showed the midline pits to be enlarged
and distorted hair follicles
• Gravity and motion may create a vacuum pulling
on the follicles
• Inflammation and debris occlude the mouth of the
follicle
• Further expansion and rupture leads to foreign
body reaction and micro abscesses
John Bascom (1925-2013)
• Lateral epithelialized tracts develop from the
abscesses, creating a sinus
• Follicular occlusion tetrad: Hidradenitis suppurativa, acne conglobata,
dissecting cellulitis, and pilonidal sinus disease
• Defect in follicular keratinization leading to obstruction of the follicle
• Retinoids to reduce size, activity, and inflammation of sebaceous glands
Pathogenesis
• Karydakis insisted that hair
insertion was the only cause of
pilonidal sinus and not an internal
etiology
• Three factors in hair insertion:
• Invader (loose hair)
• Force (causing insertion)
• Skin (vulnerability)
Pathogenesis
• Stretching of natal cleft damages hair follicles and opens a
pore
• Pores collect and embed shed hairs and debris
• Movement and skin tightening create negative pressure
• Hairs are drawn deeper and friction creates the main sinus
• Rupture and secondary infection cause foreign body reaction
and abscess with secondary lateral tracts
Macroscopy
Histology
• Hair follicle often not identified
• Tract filled with hair, debris, and granulation tissue
• Tract may be epithelialized, but not the cavity (not a
true cyst)
• Inflammation with foreign body giant cell reaction
• Secondary infection creates abscess which may rupture
Role of pathology
• Confirmation of diagnosis
• Perianal abscess
• Anorectal fistula
• Crohn disease
• Exclusion of malignancy
Perianal abscess
Anorectal fistula
Crohn disease
Malignancy
• Same mechanism as Marjolin ulcer
• Chronic inflammation impairs DNA repair mechanisms through
free radicals
• Long-standing and recurrent cases
• Average age and duration higher than usual pilonidal disease
• No carcinoma in 86,333 cases in WWII that were treated early
• Rate of transformation reported from 0.02% to 0.1%
• Underreported and under published
Safadi et al paper
• 140 cases in 103 papers from 1900 to 2022
• Mean age 54 years, males 91%
• Squamous cell carcinoma (94.6%), basal cell carcinoma, mixed
• Disease-specific survival rate of 59.8% (5-year) and 53.2% (10-
year)
• Lower survival with higher stage and higher grade
• Recurrence in 46.6%, on average within 15 months
• Worse prognosis than primary squamous cell carcinoma
• Similar to Marjolin ulcer
• Surgery is mainstay (no much role for adjuvant chemoradiotherapy)
Outcome of primary vs secondary carcinoma
Secondary squamous cell
Primary squamous cell
carcinoma from pilonidal
carcinoma
disease

3-year survival rate 95.3% 61.7%

5-year survival rate 93.6% 59.8%

10-year survival rate 93.6% 53.2%

Recurrence rate after curative

4.6% 46.6%
resection

Regional metastases at diagnosis 3.7% 8.5%

Distant metastases at diagnosis 0.2% 5.4%

Should we examine?
Thank You
The Ninth Fast Track Review - Pilonidal Sinus