Management of intergluteal pilonidal disease
- Daniel J Sullivan, MD, MPH
Daniel J Sullivan, MD, MPH
- Assistant Professor of Medicine
- Harvard Medical School
- David C Brooks, MD
David C Brooks, MD
- Associate Professor of Surgery
- Harvard Medical School
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
- Section Editors
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
Intergluteal pilonidal disease is an infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks (figure 1) . Management is variable and guided by the clinical presentation and extensiveness of disease [1-4]. The clinical manifestations and diagnosis are reviewed separately. (See "Intergluteal pilonidal disease: Clinical manifestations and diagnosis".)
An acute pilonidal abscess is managed with an incision and drainage (I&D) procedure at the time of presentation, usually under local anesthesia. This management approach is consistent with that described for a skin and subcutaneous abscess at other sites. (See "Skin abscesses, furuncles, and carbuncles", section on 'Incision and drainage'.)
The incision is generally performed lateral to the midline or over the area of maximal fluctuance, and all visible hair within the sinus is debrided [1,3-5]. Wounds are packed with gauze, and healing occurs by secondary intention in the acute setting. The wound edges may also be marsupialized (oversewing them while incorporating the base of the wound) to prevent premature closure of the skin. Curettage of the pilonidal sinus and tract at time of I&D or excision of midline pores is not typically performed in the clinical setting of an acute infection . The approach to an I&D procedure is described separately. (See "Technique of incision and drainage for skin abscess".)
An I&D, however, is not the definitive procedure for pilonidal disease, as recurrence rates range from approximately 20 to 55 percent [4,6]. In a retrospective review of 73 consecutive patients with a first episode of acute pilonidal abscess treated by I&D, 42 (58 percent) healed primarily, with a median time to healing of five weeks; 9 of the 42 developed recurrence of pilonidal disease at a median follow-up of 60 months . The overall cure rate following I&D was 45 percent.
CHRONIC OR RECURRENT DISEASE
The definitive treatment of chronic or persistent pilonidal disease is a surgical excision of all sinus tracts . The surgical procedures range from simple excision with or without primary closure to complex flap reconstruction.
- Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg 2011; 24:46.
- McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 2008; 336:868.
- Velasco AL, Dunlap WW. Pilonidal disease and hidradenitis. Surg Clin North Am 2009; 89:689.
- Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am 2010; 90:113.
- Davis BR. Pruritis ani, pilonidal sinus and hidradenitis suppurativa. www.fascrs.org/physicians/education/core_subjects/2010/Pruritus (Accessed on November 21, 2012).
- Jensen SL, Harling H. Prognosis after simple incision and drainage for a first-episode acute pilonidal abscess. Br J Surg 1988; 75:60.
- Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005; 20:415.
- Al-Khamis A, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2010; :CD006213.
- Oncel M, Kurt N, Kement M, et al. Excision and marsupialization versus sinus excision for the treatment of limited chronic pilonidal disease: a prospective, randomized trial. Tech Coloproctol 2002; 6:165.
- Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum 1983; 26:800.
- Petersen S, Koch R, Stelzner S, et al. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 2002; 45:1458.
- Nursal TZ, Ezer A, Calişkan K, et al. Prospective randomized controlled trial comparing V-Y advancement flap with primary suture methods in pilonidal disease. Am J Surg 2010; 199:170.
- Faux W, Pillai SC, Gold DM. Limberg flap for pilonidal disease: the "no-protractor" approach, 3 steps to success. Tech Coloproctol 2005; 9:153.
- Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002; 82:1169.
- Bascom J, Bascom T. Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg 2002; 137:1146.
- Bascom J, Bascom T. Utility of the cleft lift procedure in refractory pilonidal disease. Am J Surg 2007; 193:606.
- Tezel E. Cleft lift procedure with excision of pits for extensive sacrococcygeal pilonidal disease. Colorectal Dis 2006; 8:72.
- Biter LU, Beck GM, Mannaerts GH, et al. The use of negative-pressure wound therapy in pilonidal sinus disease: a randomized controlled trial comparing negative-pressure wound therapy versus standard open wound care after surgical excision. Dis Colon Rectum 2014; 57:1406.
- Al-Salamah SM, Hussain MI, Mirza SM. Excision with or without primary closure for pilonidal sinus disease. J Pak Med Assoc 2007; 57:388.
- Fazeli MS, Adel MG, Lebaschi AH. Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: results of a randomized, clinical trial. Dis Colon Rectum 2006; 49:1831.
- Karakayali F, Karagulle E, Karabulut Z, et al. Unroofing and marsupialization vs. rhomboid excision and Limberg flap in pilonidal disease: a prospective, randomized, clinical trial. Dis Colon Rectum 2009; 52:496.
- Bessa SS. Results of the lateral advancing flap operation (modified Karydakis procedure) for the management of pilonidal sinus disease. Dis Colon Rectum 2007; 50:1935.
- Bessa SS. Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study. Dis Colon Rectum 2013; 56:491.
- Arslan K, Said Kokcam S, Koksal H, et al. Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study. Tech Coloproctol 2014; 18:29.
- Doll D, Friederichs J, Boulesteix AL, et al. Surgery for asymptomatic pilonidal sinus disease. Int J Colorectal Dis 2008; 23:839.
- O'Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg 2001; 88:4.
- ACUTE ABSCESS
- CHRONIC OR RECURRENT DISEASE
- Surgical approaches
- - Excision
- - Wound closure
- Primary versus delayed closure
- Off-midline versus midline primary sutured closures
- Types of off-midline closures
- ASYMPTOMATIC INCIDENTAL SINUS
- ROLE OF ANTIBIOTICS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS