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. 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.
  • 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.
  • 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 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 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 glutal cleft is flattened – and although a wound vac may initally 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.


Common Misconceptions about the Cleft-Lift Procedure

  • False: The recovery from cleft-lift is prolonged and painful. The recovery from cleft-lift is one of the easier recoveries when compared to the various other procedures for pilonidal disease. Most patients say that the pain is minimal, and they only take analgesic pain medications for a few days. There are no open wounds, packing, or shaving. There is a small drain that is left in place for a few days, and removed in the office. Most patients are back to full activity, except contact sports, within a week.
  • False: Cleft-Lift is a “new” procedure. It depends on your definition of “new”. Dr Bascom began writing about this in the early 1990’s, and his operation is a modification of one by Dr Karydakis which was described before that. Dr Immerman has been performing this since 1993.
  • False: Most surgeons don’t perform the cleft-lift because it doesn’t work. The cleft-lift, as with every procedure, has a learning curve. If it is not done properly, it will not work, so it is important to see a pilonidal surgeon who has experience and success with the procedure. Most surgeons were not taught this procedure during their residency training and had to learn it afterwards. At our clinic the success rate is over 90%.
  • False: Not all patients with pilonidal disease are “candidates” for a cleft-lift. In medicine, anything is possible, but in the last twenty years we have never seen a patient in whom a cleft-lift was not possible. Certainly, in some patients it is more difficult than others. If a patient finds that their surgeon does not feel that they are a candidate for a cleft-lift, they should investigate whether they can find a surgeon who is more comfortable with difficult cases. We have been successfully operating on patients who have failed other operations for many years.
  • False: I’m seeing a board certified surgeon, and he is recommending wide excision – so I should follow his/her advice. In general, the advice given by a board certified general surgeon or colorectal surgeon is good and should be followed. But, in this specific situation there seem to be many surgeons who are not familiar with the cleft-lift procedure, and therefore do not address it. If it is not discussed by your surgeon – you should find a surgeon who is familiar with the procedure.
  • False: The cleft-lift is best done by a colorectal surgeon. It is strange that pilonidal disease is categorized as a colorectal problem, since it has no relationship to the colon or rectum. Many colorectal surgeons are not interested or experienced in the treatment of this disease – but others are. General surgeons and plastic surgeons may or may not have an interest in this. Dermatologists, to my knowledge, are not skilled in the cleft-lift procedure. The best guideline for finding a surgeon is to look for one who is experienced and interested in treating pilonidal disease. Our bias is that he, or she, should be experienced with cleft-lift also.
  • False: The cleft-lift procedure should be reserved for difficult, severe, or recurrent disease. Different surgeons will have different criteria for when a cleft-lift is appropriate. Some will reserve it for recurrent disease, but others view it as the first line procedure for anyone with symptoms and a deep gluteal cleft. Dr Immerman‘s personal observation is that patients don’t want the most minimal treatment, they want the most effective. Recurrences are demoralizing, disruptive, expensive, and painful. Over the last 20 years we have gone from recommending it only for the most severe cases, to recommending it to any patient with symptomatic pilonidal disease and a deep cleft. This is based on our observations, high success rate, and our attempt to get patients through this problem as quickly and pain free as possible.
  • False: If I have wide excision and it fails, I can always have a cleft-lift later. This is usually true, but the scarring and distortion from the excision will usually make the cleft-lift more difficult. In addition, the recurrent disease often appears very close to the anus, which also makes the cleft-lift harder, and may affect the success rate.
  • False: The cleft lift has a high postoperative infection rate. In our clinic, we have about a 2% infection rate with the cleft lift. This is much lower than any of the other procedures for pilonidal disease.
  • False: I’ll save time and money by seeing a local surgeon who does not perform cleft-lift. If my disease comes back, I’ll travel to see someone who does. This may or may not be wise. There are times when open excision results in prolonged healing, time off of work and school, expensive dressing changes, wound-vac application, multiple office visits, and significant discomfort. In general, the most successful procedure is also the most cost effective. In our opinion, a successful cleft-lift will be the most cost effective in the long run, even if you factor in out of pocket travel expenses.
  • False: A cleft-lift will significantly change the appearance of my buttocks. Although the procedure flattens the cleft, once things heal, the contour appears quite normal – just not the way it was before. With clothes on, there is no visible change in the size of the buttocks. There is usually a vertical scar off the center-line on one side or the other. If you would like to see a examples of how a post-op cleft-lift looks. Be aware that this is a gallery of photos of buttocks with scars! At four weeks the scar will be pink. The color should fade over 6-12 months.



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, 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.
    • 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.
    • 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.