Pilonidal sinus disease (PSD) occurs between the buttocks in the natal cleft. It is three to five times more common in men than women and is most common in those 20 to 25 years old. Genetically, a deep natal cleft, coarse hair, and hirsutism are all predisposing factors for PSD.1,2 The disease occurs in the midline starting approximately 5 cm above the anus. The process starts with a dimple and trapped hairs leading to an inflammatory sinus. Secondary abscesses and infections can be extremely painful and require surgical drainage and systemic antibiotic therapy. Asymptomatic pits1 require no surgical therapy, but acute pilonidal abscesses require lateral incision and drainage. It is at this stage that clinicians should consider early surgery.

In this issue, Kanlioz et al analyze factors affecting recurrence of the PSD after common surgical procedures. We commend the authors on collecting comprehensive retrospective data (N = 609). The investigators determined that a positive family history of PSD rendered someone seven or eight times more likely to experience PSD than healthy controls. Individuals with darker skin tone, oily skin, and excessive thick, coarse hair; fewer baths per week; and any occupation involving prolonged seating had increased susceptibility. Persons with PSD who had definitive early surgical treatment saw better results and were less likely to have a recurrence. The authors also determined that if an infected sinus was present, the infection needed to be resolved before performing the surgical procedure. If surgery was delayed for at least 4 weeks after infection resolution, recurrence was less likely. However, recurrences were more common if the individual was obese or a smoker.

Perhaps most interestingly, PSD recurrence is also linked to the treatment technique (overall 1-year recurrence rate, 58%). For example, phenol can be injected into sinuses under local anesthetic administration. Although this is an attractive option, its recurrence rate in this study was 91%.

Traditionally, the most common surgical procedure was to excise PSD with a midline closure, but the recurrence rate is high (63%). Rotational flaps have been subsequently introduced. The Karydakis flap requires placing the patient in the usual prone position and making a rhomboid asymmetric excision; a rotational flap obliterates the natal cleft. The final surgical scar is linear, and a few centimeters removed from the midline. Recurrence rates associated with this technique were reduced to 47%. The Limberg flap utilizes the same preparation but is even more asymmetric and removed from the midline (a wedge resection is followed by a wider rotational flap that leaves a semicircular scar). This technique had the lowest recurrence rate (27%). Healing by secondary intension is another alternative, where the surgeon leaves the surgical site open postoperatively. Although this approach may have a similar low rate of recurrence, the average healing time is longer.2

Local treatment of PSD is often suboptimal.1,2 Providers should examine patients in the prone jackknife position: place two pillows under the anterior hips and use the patient's hands to help separate the buttocks. Hair removal should be meticulous and performed as often as once or twice a week. Fine iris scissors may cause less trauma than shaving with a swivel head razor (pre-wet, shaving lotion, in the direction of the hair lying flat, and going over the area only once). Local hygiene can include moist towelettes to remove debris after bowel movements or a shower, preferably with a handheld shower head and liquid soap (no baths). Physical activities may increase local friction, and sitting for long periods is also harmful.

Clinicians may not adequately treat bacterial contamination and local infection on the wound surface. Topical antiseptics are needed to prevent recurrent damage. Local treatment options may include chlorhexidine, polyhexanide, or iodine, as well as foams and superabsorbent dressings molded to the wound surface to control excessive moisture. Signs of deep and surrounding infection may be subtle in the absence of surrounding cellulitis.

Finally, providers do not pay enough attention to adequate pain control and the psychosocial and sexual impact of these lesions. Ultimately, proactive PSD treatment requires comprehensive and holistic care.

R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

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