Pilonidal disease is a type of skin infection that typically occurs as a cyst between the cheeks of the buttocks and often at the upper end. Symptoms may include pain, swelling, and redness. There may also be drainage of fluid, but rarely a fever. Risk factors include obesity, family history, prolonged sitting, greater amounts of hair, and not enough exercise. The underlying mechanism is believed to involve a mechanical process where hair and skin debris get sucked into the subcutaneous tissues through skin openings called pits. Diagnosis is based on symptoms and examination. If there is an infection, treatment is generally by incision and drainage just off the midline. Shaving the area and laser hair removal may prevent recurrence. More extensive surgery may be required if the disease recurs. Antibiotics are usually not needed. Without treatment, the condition may remain long-term. About 3 per 10,000 people per year are affected, and it occurs more often in males than females. Young adults are most commonly affected. The term pilonidal means 'nest of hair'. The condition was first described in 1833.
Signs and symptoms
Pilonidal cysts can be itchy and often very painful, and typically occur between the ages of 15 and 35. Although usually found near the coccyx, the condition can also affect the navel, armpit, the cheek, or the genital region, though these locations are much rarer. Signs and symptoms may include:
Intermittent pain/discomfort or swelling above the anus or near the tailbone Opaque yellow (purulent) or bloody discharge from the tailbone area Unexpected moisture in the tailbone region Discomfort sitting on the tailbone, doing sit-ups, or riding a bicycle—any activities that roll over the tailbone area Some people with a pilonidal cyst will be asymptomatic.
Pilonidal sinus Pilonidal sinus (PNS): a sinus tract, or small channel, that may originate from the source of infection and open to the surface of the skin. Material from the cyst drains through the pilonidal sinus. A pilonidal cyst is usually painful, but if it is a draining sinus, the pressure is relieved and the patient might not feel pain.
Causes Hair insertion is the causative agent of pilonidal cysts. An analysis of 624 patients' cyst hair found that 74% of the hair was rootless, and resembled spiky, razor-cut hair rather than intact body hair. One proposed cause is ingrown hair, although hairs found in pilonidal sinus tracts have more often been found to originate from the head. Excessive sitting is thought to predispose people to the condition, as sitting increases pressure on the coccygeal region. Trauma is not believed to cause a pilonidal cyst; however, such an event may result in inflammation of an existing cyst. There are cases where this has occurred months after a localized injury to the area. Pilonidal cysts may be caused by a congenital pilonidal dimple. Excessive sweating can also contribute to the formation of a pilonidal cyst: moisture can fill a stretched hair follicle, which helps create a low-oxygen environment that promotes the growth of anaerobic bacteria, often found in pilonidal cysts. The presence of bacteria and low oxygen levels hamper wound healing and exacerbate a developing pilonidal cyst.
Differential diagnosis
A pilonidal cyst can resemble a dermoid cyst, a kind of teratoma (germ cell tumor). In particular, a pilonidal cyst in the gluteal cleft can resemble a sacrococcygeal teratoma. Correct diagnosis is important because all teratomas require consultation with an oncologist and complete surgical excision, if possible without any spillage.
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