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Answers to Questions about Pilonidal Disease

If you are not sure if you have pilonidal disease or a pilonidal cyst – follow this link for information about the diagnosis of this condition.

Below are some questions about pilonidal disease, and my answers . You will find many differing opinions among patients and doctors. These answers are my findings based on my research and almost 40 years of surgical training and practice.

    • False: It is caused by a “cyst” and removal of the cyst is the treatment. It is not caused by a cyst, it is the result of a deep cleft between the buttocks. This deep cleft causes irritation in the base of the cleft because it is never open to air. Enlarged pores develop, and sinus tracts begin to grow from the skin down into the fat underneath. Hairs get caught in these tracts, and burrow their way under the skin where they can cause discomfort, or initiate an infection. The configuration of the cleft must be adjusted in order to eradicate this process.
    • False: It only occurs in hairy men. No, it happens in women with minimal body hair as well, but it is more frequent in men. The hairs that get caught in the pits are loose hairs that get caught in the cleft and find their way into the enlarged pore. Hairs from anywhere on the body can also be shed and find they way into the gluteal cleft, but recent studies show that the hairs are usually from the back of the head. So, even women with very minimal body hair can also have pilonidal cysts.
    • False: It only occurs in people with sedentary lifestyles. This can occur in people with all kinds of activity levels, including those who are very active and those who are not. Sitting for long periods may make the pilonidal disease become more bothersome – but it does not cause the problem.
    • False: It only occurs in obese people. This is not true either. The vast majority of patients I have seen are of normal weight, or thin.
    • False: Shaving the area is necessary to prevent problems. While it is possible that shaving the buttocks and gluteal area will decrease the amount of hair that is available to get into the pores, hair that naturally is shed from other areas of your body can find their way into the pores as well. For this reason, I do not feel that local hair removal is a complete solution to pilonidal disease, nor a necessary part of all treatment regimens. I think that as physicians, we have to find solutions that are reasonable for a patient to adopt – and frequent shaving of the gluteal area is burdensome. However, if a patient’s goal is to avoid surgery, or a surgeon who can perform a cleft-lift is not available, diligent hair removal may decrease frequency of infections. But, keep in mind, as mentioned above, the hairs usually come from the back of the head.
    • Partially true: It is caused by sitting, trauma, riding a bike, etc. These activities may make pre-existing, but unrecognized, pilonidal disease suddenly become symptomatic or flare up. But, it does not cause the disease. The disease is caused by the configuration of the cleft.
    • True: It can be worsened by wearing tight clothes. Clothing such as yoga pants, stretch jeans, compression shorts and tights can squeeze the buttocks together in some patients and worsen, or even cause pilonidal disease. More about that here.
    • Mostly False: An MRI is helpful in defining whether I have pilonidal disease, and determining what operation I will need. My doctor is worried about a bone infection (osteomyelitis). I don’t agree with this, and have not found expensive MRI’s, CT Scans, or ultrasounds necessary. The visible findings on physical exam, coupled with the patient’s symptoms are all that is needed to diagnose pilonidal disease. A cleft-lift procedure, if properly done, will find and remove any tracts and prevent them from coming back. Defining them pre-operatively is not necessary. Osteomyelitis from this is extremely rare, and usually develops in patients with a predisposing disease process, other than just pilonidal disease.
    • False: Open excision has the lowest recurrence rate because it removes all the disease. Actually, it has one of the highest recurrence rates because it does not necessarily change the anatomy of the cleft. It is very frustrating to go through 3 months of wound care and healing, to have new pilonidal disease develop a few months later. A cleft-lift has the lowest recurrence rate.
    • It Depends: Sitting is not allowed for many weeks after pilonidal surgery. Although some surgeons may restrict sitting after pilonidal surgery, I never do. The weight of sitting is on the ischial bones, not over the coccyx and sacrum – so there is no significant pressure on the incision. Furthermore, there is no evidence that sitting interferes with blood flow to the surgical site; it may actually be beneficial because it keeps the gluteal crease spread open which promotes healing. Of course, patients need to be gentle with the area and avoid trauma, but I have never had a patient have a healing problem from sitting normally.
    • Debatable: If the symptoms are minimal, it is better to just live with the disease because the surgery is painful and difficult. If a physician is telling you this, then they are not familiar with cleft-lift surgery. The cleft-lift procedure is fairly straightforward, the recovery is usually quick, the recurrence rate is low, and the discomfort is usually less than having a pilonidal infection. However, since other operations for pilonidal disease are problematic – experience with these may have generated the erroneous idea that surgery for pilonidal disease usually fails.
    • False: Topical treatments or antibiotics can cure pilonidal disease. There are no known creams, lotions, homeopathic remedies, antiseptics, or antibiotics that will make the pilonidal disease under the skin resolve. It is possible, with diligent wound care to get the outward openings, such as the sinus tracts or pores, to heal shut temporarily; and antibiotics can make a flare up with pain or infection subside. But, the disease can still exist under the skin waiting for a time to become symptomatic. The most effective way to promote external healing is to allow air to circulate around the affected skin – usually by placing a dry gauze pad between the buttocks and changing it frequently. Some patients have described temporary success with topical Tea Tree Oil, oregano oil, or MediHoney – which are effective antimicrobials and anti-inflammatory agents. But, they do not address the basic cause of the problem, which is a deep cleft; nor do they address the subcutaneous pockets of hair. It is not unreasonable to try these topical methods – but it often leads to a disappointing recurrence. Long term use of these topical agents can effectively turn a curable problem into a chronic disease.
    • Often False: Silver nitrate helps wounds heal. This is a caustic chemical that has very limited usefulness in the treatment of pilonidal disease. It chemically burns and destroys cells. It will not make a wound that isn’t healing because of its position in the cleft suddenly heal closed. It’s only utility is in situations where there is chronic inflammation, and there is exuberant healing with heaped up granulation tissue coming out of an incision or open area. By destroying the excessive granulation tissue, it can help the skin close and stop the drainage coming from the granulation tissue. Except in this very unusual instance, it is counter-productive to healing and should be avoided.
    • Sometimes true: A wound vac is a good solution for healing pilonidal wounds. A wound vac is an excellent way to speed up the healing of wounds that normally would heal if given enough time. Unfortunately, pilonidal wounds often will not heal until the gluteal cleft is flattened – and although a wound vac may initially speed up healing, they do not do anything to prevent recurrence of the pilonidal disease. A wound vac is often a temporary measure that gives the illusion of solving the problem, but sadly does not. It is a cumbersome, time consuming, uncomfortable, expensive, and awkward solution for young active patients. A cleft lift is a much quicker and less painful solution.

      Answers to Questions about a Pilonidal Abscess

    • It Depends: I had a pilonidal abscess drained, and now it looks and feels good. They told me I don’t have to do anything else. Well, although it is possible that you won’t have any further problems – many patients do go on to have recurrent problems months or years in the future. And, this usually occurs at the worst possible time, such as when you’ve just started a new job, have no insurance, are on vacation, are preparing to get married, etc.. My advice is to consider having a definitive procedure, like a cleft-lift, in the near future at a convenient time. It is totally acceptable to take a “wait and see” approach as long as you are aware of the possible outcome.
    • Usually False: A pilonidal abscess, after being drained, needs to be “packed”, and the gauze removed slowly over a period of time. Once drained (also referred to as “lanced”), a pilonidal abscess heals quickly. In my experience, packing the abscess cavity actually slows down the healing. Unfortunately, there is not universal agreement with my observations. I rarely insert packing or any kind of a drain for an acute abscess (unless it is enormous in size). As long as an adequate incision is made to properly drain the abscess, the infection will quickly resolve, the abscess cavity will close, and the patient will feel better very quickly. Antibiotics may help speed up the recovery – but are probably not absolutely essential. Packing is painful and scary.
    • False: The only way to drain a pilonidal abscess is in the clinic with local anesthesia. These can be drained in the office under local anesthesia, in the operating room with sedation or general anesthesia, or somewhere in-between. How it is done depends on what the patient wants. If the abscess is clearly defined and ready to “pop”, it is usually pretty easy and quick to do this in the clinic. But, if the patient has pain – but the outward visible signs are vague – draining this in the operating room with IV sedation is my preference.
    • False: It is useful to culture the drainage from pilonidal disease, or an abscess that develops. This does not provide useful information. We find various different organisms, but the treatment is surgical drainage for an abscess, or a cleft-lift for chronic disease. When an abscess is drained, we usually start antibiotics based on our guess of the bacteria involved. By the time we have culture and sensitivity results, the abscess has usually resolved. Before a cleft-lift procedure, patients are treated with antibiotics that cover gram positive and gram negative and anaerobic bacteria. Studies of the kinds of bacteria involved show a preponderance of anaerobic bacteria, so antibiotics like metronidazole (Flagyl), Clindamycin or Augmentin are often used.
    • False: Antibiotic ointments will speed up healing. In this situation antibiotic ointments do not make the abscess resolve more quickly, or the open area heal faster. Some patients develop a rash from topical antibiotic ointments like Bacitracin, Neosporin or Polysporin. In addition, the ointments trap moisture and can make the bacterial situation worse than without them. So, I would say that they are not helpful, and may be counter-productive. The best local wound care is to keep the open area clean and dry; either a bath or shower is fine. The idea is to wash away the debris in as comfortable a method as possible. Then, keep a dry gauze pad over the area to absorb any new drainage.
    • False: Hydrogen peroxide is harmful to the wound. The reason that this is often said is that hydrogen peroxide can be harmful to normal cells and slow wound healing. However, in the situation where you are dealing with inflamed, dead tissue with pus and exudate – it is a good antiseptic to decrease the number of bacteria (mostly to help with the odor), and its foaming action will help remove dead tissue and dried fluids. It will not significantly speed up resolution of the problem – but I don’t think it will have any harmful effects either.
    • Mostly False: Epsom Salt bath will speed up healing. Soaking in a bath a few times a day to wash away drainage and debris is a good idea. The addition of Epsom Salts (magnesium sulfate) has not been proven to really speed up the resolution of the infection. Personally, I doubt it will hurt, but is probably not a necessary addition to the bath water.