What is a good strategy for dealing with pilonidal wounds?
If you are a clinician working in a wound clinic, it would not be uncommon for a surgeon to refer a patient to you with a non-healing wound after pilonidal surgery. Unfortunately, wounds in the gluteal crease are not like wounds elsewhere on the body, and the usual strategies for dealing with wounds may not apply here.
The problem with the gluteal crease is that in spite of how it may look with the patient lying prone on an examining table, most of the day the patient is not lying prone, and the patient’s position changes the depth of the gluteal fold when standing, sitting, and moving about. The cleft is the flattest with the patient prone, and the most folded when standing. The environment in the cleft is not conducive to healing: it is moist, laden with anaerobic bacteria and there is pressure in the cleft from the folded skin. Something that might heal easily on an ankle, just may not heal in this hostile environment. It is not unusual for a wound to appear to be healing with diligent wound care, only to open again once wound care is ceased. These wounds give the appearance of healing, but it is very tenuous and the slightest distraction force pulls it apart.
What strategies are helpful?
The environment around the wound is the problem, and all attempts should be made to both control the environment and optimize healing.
- The number one goal is to allow the wound access to air. Occlusive dressings are the opposite of what is needed. Often, just tucking dry, WOVEN, gauze in the crease is all that is needed to get air in there. This prevents any pressure from building up, as well as spreading the cleft open for air circulation.
- The area must be kept dry. This may be difficult with a weeping wound, but changing the woven gauze frequently will help. Applying cool air with a hair dryer on the cool setting after showering or before putting in new gauze is a good strategy as well. If the surrounding skin is damaged by chronic moisture and irritation, applying an antacid like Maalox or Mylanta and drying with a hair dryer can be very beneficial.
- Anaerobic bacteria should be controlled. The best method for this is 10% metronidazole ointment which is not available as a brand name product in the U.S. but is easily made by any compounding pharmacy. This works particularly well with wounds very close to the anus.
- Attention should be given to the patient’s nutritional status. A high protein diet with appropriate vitamins and supplements is essential. You can read my recommendations here.
- Avoid wound VAC devices. This is a difficult area to get a good fit, they are smelly and cumbersome, and may just give the illusion of healing.
- Don’t obsess about hair removal. The only reason to recommend hair removal is if the patient has so much hair that it makes it difficult to keep the area clean and dry. The presence of hair does not create or prolong pilonidal disease, and hair removal on the torso is not particuarly valuable because most of the hair in pilonidal cysts come from the back of the patient’s head.
- Never use silver nitrate. This just damages the wound.
How long should healing take?
If this is going to work, NO LONGER THAN 6-8 WEEKS SHOULD BE ALLOWED. After that time period, you are subjecting the patient to chronic wound care that is not necessary and very well may result in failure or recurrence. I say that it is not necessary, because there is a surgical solution that is straightforward and uniformly successful: a cleft-lift by an experienced surgeon. There is no wound too close to the anus for a cleft-lift to be successful in the proper hands. The following link shows what we tell patients about why their wounds won’t heal, and what they should do: Dealing with Failed Operations.
Although a surgeon may have referred the patient to you, and indicated that there is no surgical solution, that surgeon may not be aware of the success of the cleft-lift procedure in expert hands, and is not giving the patient the best advice. Some of my most grateful patients were referred from a wound clinic for a cleft-lift which proved to be successful. In general, these patients make surgeons unhappy, and they are quite willing to have them go elsewhere for care.
I hope this is helpful. If you have questions or comments, feel free to write me through the CONTACT form on this website.