From
Dr. Nelson G. Rosen
Evaluation and management of pilonidal disease in adolescents
With Dr. Nelson G. Rosen · hosted by Dr. Paul Bunch
Chapter 1 of 12
Introduction
Introduction and Guest Background
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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Published Oct 2023
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What the experts said
Pilonidal disease does not occur before adolescence
Occasionally pilonidal disease is seen in 10-year-olds who are starting puberty but not advanced on the Tanner scale
The Cincinnati center sees over 200 pilonidal patients per year
Most pilonidal patients present in middle to late adolescence
Pilonidal disease involves hairs from the outside working into tiny openings and getting stuck under the skin, not ingrown hairs
The most common pilonidal phenotype is an abscess cavity that drains spontaneously through a different location, usually at the top of the cleft on left or right, sometimes middle or bottom
Some patients present with acute abscess without spontaneous drainage, experiencing severe pain and inability to sit
Some patients drain too efficiently and develop open wounds in the cleft that don't cause pain, leading to delayed presentation with wounds that have been draining for months
Pilonidal disease involves mixed bacterial flora including gram positives, gram negatives, and always anaerobes
Cultures are primarily useful for non-responders to initial treatment rather than for routine management
In the pediatric population, pilonidal disease affects males and females equally (50/50 ratio)
In the adult population, pilonidal disease affects approximately 75% men, likely because adult women are not presenting or being diagnosed
Pilonidal disease affects all body types: hairy and non-hairy people, thin and heavy people, sweaty and dry people, those with poor and excellent hygiene
Most pilonidal patients do not have a family history, but some do report affected family members
A subset of patients have both pilonidal disease and Crohn's disease as separate but potentially related processes
The two most important comorbidities for pilonidal management are inflammatory bowel disease and diabetes
Pilonidal pits are visible pores in the direct midline that are larger than surrounding pores, typically 1-2 millimeters
Pilonidal sinuses are holes in the midline that are 3 millimeters or larger, with visible depth
Pilonidal wounds are openings 1 centimeter or larger where beefy raw surface is visible
Patients whose pilonidal drainage opening tracks down near the anus can be misdiagnosed as having perianal fistula or Crohn's disease
Examination under anesthesia may be needed to definitively distinguish pilonidal disease from perianal fistula when the drainage opening is very low
Not all pilonidal patients require surgery; some can be managed with laser hair removal and conservative measures
The cleft lift (modified Karydakis flap) is a wide excision with off-midline closure that has over 90% success rate
The cleft lift procedure takes about 2.5 hours of anesthesia, requires narcotic pain medicine, and involves a drain for about 5 days
The Gips procedure is a 20-minute outpatient procedure done under sedation
Traditional wide excisions with midline closure have high failure rates and should be avoided
For acute pilonidal abscess, needle aspiration with an 18-gauge needle can confirm presence of pus before making an incision
First-line antibiotics for pilonidal abscess include Cipro and Flagyl, Augmentin, Clindamycin, or Bactrim with Metronidazole for anaerobic coverage
Sitz baths are not emphasized because most patients will not comply with this time-intensive treatment
After acute abscess drainage, patients should be seen back in 1-2 weeks to reassess and determine if minimally invasive procedure is needed
Patients who present with acute abscess and no visible pits may show pits 3-4 weeks later after the infection clears and swelling resolves
Sacral osteomyelitis in pilonidal disease is rare, occurring in approximately 1 in 1000 cases
There is no role for routine imaging (ultrasound or MRI) in pilonidal disease management
If imaging is being considered for pilonidal disease, that is an indication to refer to a specialist
John Bascom's theory: pilonidal develops from infection around hair follicle, hair falls out leaving a large pore called a pit, then hairs from outside work into that opening
John Armstrong's military study showed that shaving pilonidal patients once a week led to resolution over time in many cases without surgery
Clipping hair before surgery results in lower wound infection rates compared to shaving
The Gips procedure is a minimally invasive technique that uses small punches to remove pits and sinuses, then cleans out the inside through these openings