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1. Pilonidal Disease
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. Outline
• Background
• Introduction
– Definition
– Etymology
– Classification
• Epidemiology
• Pathophysiology
• Etiology
• Clinical Manifestation
• Differential Diagnosis
• Workup
• Treatment
• Complications
• Prognosis

3. BACKGROUND-Journey from historical congenital
theories to new acquired theories
• Described back as far as 1833, when Herbert Mayo described a
hair-containing cyst located just below the coccyx
• R.M.Hodge coined the term "pilonidal" from its Latin origins in 1880
• In the 19th and early 20th centuries
– studied on an embryologic basis by many authors, considering it to be
of congenital origin.
– congenital remnant of an epithelial-lined tract from postcoccygeal
epidermal cell rests or vestigial scent cells
– Excision of the lesion was thought to be fundamental to removing all
embryologic remnants

4. BACKGROUND-Journey from historical congenital
theories to new acquired theories
• Gained prominence and practical importance amongst World War II soldiers
with a high incidence of the disease, so much so it came to be known as
Jeep seat/ Jeep(riders‘) disease (Jeep/driver’s bottom)*
– nearly 80,000 US soldiers were admitted and treated at US Army
Hospitals between the years 1941-1945 with average hospital stay time
of 55 days
– Prompt return of soldiers to the field was important, leading to a variety
of proposed surgical treatments aimed at this goal
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*large portion of people who were being hospitalized for it rode in Jeeps, and prolonged rides in
the bumpy vehicles were believed to have caused the condition due to irritation and pressure
on the coccyx

5. BACKGROUND-Journey from historical congenital
theories to new acquired theories
• After the war, Patey and Scarf hypothesized the acquired
origin of pilonidal disease
– penetration of hair into the subcutaneous tissue with consequent
granulomatous reaction
– basing this theory on
• the high incidence of recurrence, as well as
• occurrence of disease in other areas of the body, such as the hands of a
barber or sheep shearer
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an acquired etiology of the disease is now the prevailing theory in the medical world

6. BACKGROUND-Journey from historical congenital
theories to new acquired theories
EVIDENCE IN FAVOR OF ACQUIRED THEORY OF ORIGIN
• Interdigital pilonidal sinus is an occupational disease of
hairdresser
– Hair within interidigital cleft(s) being from costumers
– Pilonidal sinus of axilla and umbilicus also reported
• Age incidence of appearance of pilonidal sinus(82 % occur
between 20-29 year) is at variance with age of onset of
congenital lesions
• Hair follicles have almost never been demonstrated in walls of
sinus and are lined with cuboidal epithelium

7. BACKGROUND-Journey from historical congenital
theories to new acquired theories
EVIDENCE IN FAVOR OF ACQUIRED THEORY OF ORIGIN
• Hairs projecting from sinus are dead hairs, with their pointed
ends directed towards the blind end of the sinus
• Disease mostly affects men, in particularly hairy men
• Recurrence is common, even though adequate excision of
track is carried out

8. Definition
PILONIDAL DISEASE
Spectrum of clinical presentations, ranging from
asymptomatic hair-containing cysts and sinuses to
large symptomatic abscesses of the sacrococcygeal
region that have some tendency to recur
(includes pilonidal abscess, sinus, cyst and fistula)

9. Definition
PILONIDAL SINUS
Condition found in the natal cleft overlying the
coccyx, consisting of 1 or more, usually non-infected,
midline openings, which communicate with a fibrous
track lined by granulation tissue and containing hair
lying loosely within the lumen

10. Etymology
Pilonidal means “nest of hair”
derived from the Latin words for hair (pilus) and
nest (nidus)

11. Classification
• 3 categories that represent different stages of
the clinical course
– (1) acute pilonidal abscess,
– (2) chronic pilonidal disease, and
– (3) complex or recurrent pilonidal disease.
• Ideal treatment varies according to the clinical
presentation/category of the disease

12. Epidemiology
WORLDWIDE INCIDENCE
7 per 10000 population
Gender Predisposition
Adult M:F ( 3-4 : 1)
Children  M:F (1 : 4)
RACE
predominantly in white/Caucasians

13. Epidemiology
AGE*
typically in the late teens to early twenties,
decreasing after age 25 and
rarely occurs after age 40
average age of presentation 21 years(male) and 19 years(female) **
__________________________________________________
*it occurs after puberty, when sex hormones are known to affect the
pilosebaceous gland and change healthy body hair growth
**due to the fact that puberty occurs earlier in females

14. Pathophysiology
SAME AS FOR ACNE VULGARIS/HIDRADENITIS SUPPURATIVA
• Sex hormones affect the pilosebaceous glands after onset of puberty
– Hair follicle becomes distended with keratin.
– Resulting in folliculitis, leading to edema and follicle occlusion.
– Infected follicle extends and ruptures into the subcutaneous tissue, forming a
pilonidal abscess.
• resulting in a sinus tract leading to a deep, subcutaneous cavity.
• Direction of the sinus tract is cephalad(90%),
– coincides with the directional growth of the hair follicle.
– Places the tracking follicle approximately 5-8 cm from the anus.
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ACNE/FOLLICULAR OCCLUSION TETRAD = hidradenitis suppurativa, acne conglobata, dissecting
cellulitis of the scalp, and pilonidal sinus

15. Pathophysiology
– In the rarer 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 (intergluteal) cleft becomes an
epithelialized tube.
– The laterally draining tract becomes a granulating sinus tract opening

16. Pathophysiology
Buttock friction
+ shearing
forces in natal
cleft
Allows shed
hair or broken
hairs collected
in natal cleft
To DRILL
through midline
skin
1st MECHANISM

17. Pathophysiology
Infection in
relation to hair
follicle
+ suction
created by
buttocks
movements
Allows hair to
enter skin
2nd MECHANISM

18. Pathophysiology
Both mentioned mechanism
Create a subcutaneous, chronically
infected, midline track (PRIMARY SINUS)
SECONDARY TRACKS may spread laterally
from primary sinus
Emerge at skin as granulation tissue lined
discharging openings

19. Pathophysiology
• Microscopically, the sinus tract where the hair enters is lined with
stratified squamous epithelium with slight cornification (itself soft)
– Additional sinuses are frequent.
– sinus tract openings are actually an extension of the deep cavity
• Cyst/sinus cavities are lined with chronic granulation tissue and may
contain hair, epithelial debris, and young granulation tissue.
– Cutaneous appendages are not seen in the wall of cysts.
– Cellular infiltration consists of PMNs, lymphocytes, and plasma cells in varying
proportions.
– Foreign body giant cells in association with dead hairs are a frequent finding.
• Hair enters tip first, and the barbs on the hair prevent it from being
expelled, causing the hair to become entrapped.
– Physical examination occasionally may reveal a tuft of hair emerging from the
midline opening in the natal cleft.

20. Pathophysiology
3 pieces are instrumental in this process:
(1) the invader, hair;
(2) the force, causing hair penetration; and
(3) the vulnerability of the skin.
__________________________________________________________________
This process has been well characterized by Patey and Scarff as
well as a number of other authors from the second half of the
20th century through today

21. Pathophysiology
MICROBIOLOGY
most commonly reported bacteria cultured from pilonidal
abscesses differ by author
• In one study, anaerobic cocci were present 77% of the time;
aerobic, 4%; and mixed aerobic and anaerobic, 17%.
• Other studies quote Staphylococcus aureus, an aerobe, as
being the most common bacterial pathogen.

22. Pathophysiology
• 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 came from a
bird's feather, the type used to stuff feather
bedding.

23. Etiology- risk factors
• Male gender
• Hirsute individuals
• Dark (stiff) haired individuals rather
than softer blond hair
– Rare in Negroes
• Increased sweating/moisture
• Sitting occupations (or sedentary
lifestyle)-friction movements
– Driver of vehicle(own hair)
– Barber(customer hair)
– bird keeper/sheep keeper(Animal hair)
• folliculitis or a furuncle at another
site on the body
• Deep/narrow natal cleft
• Hair within the natal cleft (local irritation)
• Family history (38 % areas)
• Obesity
– risk factor for recurrent disease
– Buttock friction
• Other hair features
– Kinking(shape), medullation(nature)
sharp/coarseness, and growth rate
• Poor personal hygiene
• Local trauma(army recruits)

24. Clinical Manifestation
• Most common presentation in the ER is a intermittent painful
(persistent, throbbing), swollen discharging (serosanguinous/
purulent) lesion in the sacrococcygeal region about 4-5 cm
posterior to the anal orifice
– May be asymptomatic
• At times, spontaneous drainage may have occurred prior to
presentation to the clinician
• Occasionally, a history of trauma is recalled
• Patient may state that a similar lesion occurred in that area before,
for which the patient may have had a primary incision and
drainage or other definitive care prior to this presentation.

25. Clinical Presentation
• Given most patients are young and healthy, other
comorbidities are not common, and review of systems
is often negative, including fever and chills.
• There is no known preponderance of this disease in
smokers or alcohol or drug abusers.
• Although usually found near the coccyx/natal
(intergluteal) cleft /sacrococcygeal region
– Condition can also affect the umbilicus, web spaces of hand,
armpit or genital region (though rarer)

26. Sacrococcygeal Pilonidal Disease

27. Clinical Presentation
• Usually, the patient is afebrile and nontoxic(minimum
constitutional symptoms)
• Local examination may show a relatively unremarkable sinus
tract in the sacrococcygeal region
– Primary sinus having 1 or more openings
• All strictly in the midline, with tuft of hairs seen in opening of sinus
• Between level of sacrococcygeal joint and tip of coccyx
• or may have secondary lateral openings superior to the midline pit.
• Usually at ER presentation, the patient has typical findings of an
abscess, including redness, warmth, local tenderness, and fluctuance
with or without induration.

29. Differential Diagnosis
• Anal Fistulas and Fissures
• Hidradenitis Suppurativa
• Perirectal Abscess
• Syphilis
• Tuberculosis
• Osteomyelitis of Coccyx

30. Workup
• No specific laboratory studies or tests are needed to
diagnose pilonidal disease and its sequelae or
differentiate it from other disease entities
– It is a clinical diagnosis best elicited by history and physical
examination findings.

31. Treatment
• Conservative treatment
– INDICATION: patients whose symptoms are
relatively minor( and without abscess)
• natural history of condition is usually one of regression
– Cleaning out the tracks and removal of all hair,
with regular shaving of area and strict hygiene

32. Treatment
• Pilonidal Abscess(acute exacerbation)
– Conservative
• Rest, baths, local antiseptic dressings and broad-
spectrum antibiotics
– Surgery
• Incision and drainage
– Small longitudinal incision made over the abscess and off the
midline
– Through curettage of granulation tissue and hair
– May or may not be associated with complete resolution

33. Treatment
• Chronic Pilonidal Disease
– Lack of overall superiority of 1 method over others
– Factors affecting choice of method
• Time spent off work
• Perceived recurrence rates
• Surgeon preference
– Goals of the ideal procedure should be
• Reliable wound healing
• Low risk of recurrence
• Short period of hospitalization
• minimal inconvenience to the patient(low morbidity)
• few wound-management problems.
• Resumption to normal daily activities as quickly as possible.

34. Treatment
• POSITION: Jack Knife*(Kraske position) (prone with buttocks elevated)
• Anesthesia: General or Local
• OPTIONS
– Laying open & curetting of all tracks(demonstrated by methylene blue) +/-
marsupialisation
– Excision of all tracks with
• OPEN METHOD: wound left open-secondary intention healing over 3-4 weeks (Least recurrence)
• CLOSED METHOD:
– primary closure(+/- retention suturing)
– closure by some other means designed to avoid a midline wound
» Z-plasty,
» Karydakis procedure
• semilateral incision and lateralised suturing of wound away from midline
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*Jackknifing means the folding of an articulated vehicle (such as one towing a trailer) such
that it resembles the acute angle of a folding pocket knife

35. Cleft left procedure

37. – Bascom’s procedure
• Incision(s) 2-4 mm sized lateral to midline to gain access
to sinus cavity
• Pus drained, hairs removed with only minima/NO
excision of sinus/cavity wall
• Most effective for primary pilonidal sinuses

38. Treatment
POSTOPERATIVE CARE
• Daily pack/dressing change after warm shower/sitz bath
• elimination of hair (ingrown, local or other) from the wound every
1-3 weeks
– as effective in preventing recurrence as a secondary surgical
procedure
FOLLOW UP
• After 1-2 weeks
– examine the wound for healing,
– assess for potential recurrence,
– arrange for definitive care of the sacrococcygeal region if
necessary

39. Treatment
RECURRENT PILONIDAL SINUS
ETIOLOGY
• Part of sinus complex overlooked at primary operation
• New hairs enter the skin or the scar
• Persistence of a midline wound caused by shearing forces and scarring
TREATMENT
– Revisional surgery including extensive resection/re-excision followed by
wound closure and obliteration of natal cleft either by
• (Limberg-single/double Rhomboid) myocutaneous rotational buttock flap
• V-Y gluteal advancement flap

41. Treatment
CONTRAINDICATION
• Although no specific contraindications exist for
the treatment of pilonidal disease, consider the
patient's overall situation and well-being
– weigh the complexity of the proposed surgical
procedure against the patient's individual
comorbidities and long-term prognosis.

42. Complications
• Recurrence of the abscess
– most common complication(40-50 %)
• Wound infection
– Leading to sacral osteomyelitis, necrotising fascitis and
rarely meningitis
• SCC in chronic pilonidal disease
– Exceedingly rare
– requires en bloc surgical resection and appropriate
oncologic care with local radiation and possibly
chemotherapy

43. Prognosis
• Excellent long-term prognosis
• Mortality is practically NIL
– unless SCC develops,
– though abscess recurrence is common