Pilonidal cyst

A pilonidal cyst is a cavity that forms under the skin. It is secondary to the accumulation of hair that has penetrated the dermis (skin), most often through a small dimple present in the gluteal fold. The most common location is in the sacro-coccygeal region (hence the old name of sacro-coccygeal cyst) near the tailbone at the top of the buttocks.

Rootless hairs penetrate the skin in the gluteal cleft and create a cyst which can become intermittently infected.

Incidence:   

– France: 26 cases per 100,000 inhabitants

– Turkey: 7 cases per 100 people between 17 and 28 years old.

Men are affected more frequently.

Most common age: 15 – 25 years.

Rare after 40 years.

Not infected

Due to the location, many patients are not aware that they have a pilonidal cyst, as long as the cyst remains asymptomatic. Sometimes a small dimple in the gluteal cleft is noticed with or without hair in the dimple or as a result of oozing from the gluteal cleft.

infected

The patient presents with pain, swelling and redness in the gluteal cleft.

The patient may also present with pain in the groove which is relieved by intermittent discharge of a foul-smelling fluid.

Type of hair:

People with harder  texture  and more abundant hair are more likely to develop a pilonidal cyst. The Mediterranean population (Portuguese, Italians, Greeks, Turks…) are more likely to develop pilonidal cysts. This does not mean that a blond Swede can not develop a pilonidal cyst.

Anatomy of the gluteal fold:

Patients with a deep gluteal cleft (“tight buttock”) are at greater risk of developing a pilonidal cyst.

Hormonal factors:

The peak incidence (occurrence) between the ages of 15 and 25 is probably due to the hormonal balance at young age.

Pilonidal cyst is associated with other hormonally influenced skin diseases such as acne and hydradenitis suppurativa. When pilonidal cyst is associated with acne and/or hydradenitis suppurativa the risk of recurrence of pilonidal cyst in case of treatment is higher.

Family factor:

If someone in the family has had a pilonidal cyst, the risk of recurrence increases by 12%.

Perineal hygiene:

Perineal hygiene is recommended so that hair cannot remain in the gluteal groove and does not have time to penetrate the skin in the gluteal groove.

Studies have not shown that sweating and obesity increases the risk of pilonidal cysts.

No shaving!

Shaving increases the risk of pilonidal cysts and increases the risk of recurrence. Shaving increases the number of rootless hairs in the gluteal cleft, which doubles the risk of developping  pilonidal cysts.

Laser hair removal

Laser hair removal can reduce the risk of pilonidal cysts, but the risk is not reduced to zero! Given the (non-reimbursed) cost of total hair removal from the lumbar region, back and perineum without a guarantee of no recurrence comes at a certain cost, patients cannot be forced to undergo total hair removal.

No, there is no increased risk of cancer.

Treatment of an asymptomatic pilonidal cyst

A dimple in the gluteal cleft should not be treated, if a hair is visible in the dimple it should just be removed if possible. Maintain perineal hygiene to prevent hair from remaining in the groove and penetrating the skin.

Patients may present with pain and/or swelling in the gluteal area, or a sudden malodorous oozing after a painful episode.

Treatment consists of incision of the abscess off centerline of the gluteal fold and drainage of pus.

In the first line, minimal invasive surgery is attempted, which consists of excising the pits and removing the sinus wall followed by flushing the cavity. The remaining cavity is obliterated with a laser or radio frequency fiber.

We still very rarely perform excision and primary closure of a pinolidal cyst.

The healing of an open wound in the gluteal fold can take several months to heal with an impact on social life, school or professional activity (on average more than 1 month).

See surgical procedure : Treatment pilonidal cyst- radio frequency / laser ablation

If despite minimal invasive surgical treatment or if the patient presents with a very large chronic infectious pilonidal cyst, a skin flap can be proposed, which consists of resecting the cyst and sliding the skin so that the intergluteal fold is attenuated and the suture is offset from the median line.

See surgical procedure : Treatment pilonidal cyst with «karydakis» skin flap.