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Perhaps the least glamorous condition I care is pilonidal disease. However, helping patients with the problem is one of the most rewarding parts of my practice. Unless you or a loved one  have suffered from a pilonidal problem, you probably aren’t familiar with it. Those who have the condition know that it can cause a great deal of pain while being debilitating and embarrassing.

What is Pilonidal Disease?
Pilonidal disease is a chronic or acute inflammation of the skin and soft tissues at  base of the tailbone in the cleft between the buttocks (“butt crack” or “natal cleft”). It’s commonly called a pilonidal cyst, but I find that that name is misleading because it implies that there is a growth that needs to be removed. “Pilonidal” means “nest of hair” with hair becoming impacted or collected under the skin leading to chronic inflammation and sometimes infection. I have occasionally seen some cases of pilonidal disease of the belly button.

There are two variants of pilonidal disease: the pilonidal abscess and the pilonidal sinus. When the area at the base of the tailbone becomes infected, an abscess can develop. This red, tender, swollen area is filled with pus and hair. Once an abscess drains, the moist, dark, constantly moving natal cleft is difficult to heal. The chronic draining wound left behind is called a pilonidal sinus.

What Causes Pilonidal Disease?
The theory that I favor is that a hair penetrates the bottom of a follicle creating a small pit. This pit then acts like a suction cup pulling hair, skin cells, and germs under the skin. Over time the collection grows and becomes an abscess or a sinus.

Risk factors include obesity, having a lot of hair, and living in a warm, humid climate. Where I live, with a predominantly Mediterranean population living in the subtropics, pilonidal disease is common. That being said, I have seen thin, hairless people with pilonidal disease. I don’t have an explanation for this.

Treatment of Pilonidal Disease
The approach to treatment will vary from patient to patient depending on the nature of the disease. In all cases hair removal and excellent hygiene are paramount!

I treat an early abscess, characterized by redness and pain, but without a large pocket of pus, with warm compresses and antibiotics.

I will drain a more developed abscess, usually with some sedation and local anesthesia. The most important part of the procedure is not opening the skin in the midline at the bottom of the natal cleft, because wounds in that location are unlikely to heal.

Most pilonidal sinuses will heal with conservative therapy of hair removal and topical antibiotics. Much like how an earring keeps a piercing from healing, hair keeps the wound from healing. For sinuses that don’t heal with conservative therapy, I will debride, or scrape out, the wound with the patient under sedation and local anesthesia.

When a patient has pilonidal disease that is severe, or has failed other approaches, I will take him to the operating room and perform a cleft lift. A cleft lift is a bigger operation that involves removing some of the affected skin, mobilizing a skin flap, and closing the wound with stitches. I find that only about 1/10 of my patients will need a surgery like this.

Outlook
Pilonidal disease can be painful and embarrassing. However, with proper and appropriate care, patients with this condition can be helped.