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Pilonidal Disease

Pilonidal Disease is a chronic inflammatory condition of the skin and subcutaneous tissues above the coccyx in the buttock cleft. This disease typically features the formation of infections, Pilonidal Cysts, and Pilonidal sinuses, often requiring medical intervention to alleviate symptoms and prevent a recurrence.

Symptoms

Pilonidal Disease symptoms can vary depending on the severity and stage of the condition. Here are some common symptoms:

Early Symptoms	Mild discomfort or pain: Slight discomfort or pain above the coccyx in the buttock cleft, significantly worsened after prolonged sitting or activity. Small lump or hard knot: Small lumps or hard knots felt beneath the skin above the coccyx, which may be initial cyst formation or sinus tracts.
Intermediate Symptoms	Increased pain: Pain becomes more intense, particularly when sitting, standing, or moving. Pain may radiate to surrounding areas, affecting daily activities. Redness and inflammation: Skin over the affected area becomes red, swollen, and warm. The skin surface may become fragile and sensitive. Pus and blood drainage: Sinus tracts or cysts may rupture, leading to drainage of pus or blood. The discharged fluid may have an odour and signs of infection.
Severe or Chronic Symptoms	Recurrent infections: Inadequately treated conditions may lead to recurrent infections. Each infection may worsen symptoms and increase the difficulty of treatment. Formation of sinus tracts: Recurrent inflammation and infections may result in multiple sinus tracts, creating numerous small openings on the skin surface. These tracts may communicate with each other, forming complex paths of infection. Enlarged lump: Cysts may enlarge, forming a noticeable lump with an intricate knot felt upon touch. The lump may compress surrounding tissues, causing more discomfort and pain. Fever and systemic discomfort: During severe infections, patients may experience fever, overall weakness, and malaise. These systemic symptoms indicate the spread of disease and require immediate medical intervention. Itchy skin sensation: The skin over the affected area may itch, especially during healing. Difficulty draining pus: Severe infections or larger cysts may make it challenging to drain pus, necessitating drainage by a healthcare professional

Early identification and treatment of these symptoms are crucial to prevent worsening of the condition and complications. Patients are advised to seek medical attention promptly upon experiencing the above symptoms to ensure correct diagnosis and treatment.

Pilonidal Disease most commonly includes Pilonidal Sinus and Pilonidal Cyst, both related conditions associated with pilonidal disease and often used interchangeably in clinical practice. Still, they have distinct differences in strict terms. Here are their distinctions:

Pilonidal Sinus

Definition: A small or multiple small sinus tract(s) formed in the skin and subcutaneous tissue above the coccyx. These sinuses typically extend to the skin surface and may intermittently discharge pus or blood.
Cause: Mainly due to hair penetration into the skin and subsequent foreign body reaction, leading to inflammation and infection. The formation of sinuses is associated with recurrent infections and inflammation, which are common in hair-rich areas.
Symptoms: Swelling, redness, and pain. Sinus openings may discharge pus or blood. It can recur, leading to chronic sinuses.

Pilonidal Cyst

Definition: A cystic swelling above the coccyx containing hair, sebum, sweat, and skin debris. These cysts can become infected and develop into abscesses.
Cause: Foreign bodies such as hair and skin debris embed into subcutaneous tissue, forming cystic swellings. When infected, cysts may develop into abscesses.
Symptoms: A noticeable lump formed above the coccyx, which may be tender to touch. Infection may fill the cyst with pus, causing redness and severe pain. Pus or blood discharge may occur.

	Pilonidal Sinus	Pilonidal Cyst
Structure and Morphology	It is a sinus tract structure, typically small and narrow, extending to the skin surface. The sinus can have multiple small openings and may intermittently discharge pus or blood.	It is a cystic structure containing hair, sebum, sweat, and skin debris, typically round or oval. When infected, the cyst may become an abscess filled with pus, causing severe pain and significant swelling.
Clinical Presentation	Main symptoms include mild swelling, redness, and pain. Sinus openings may discharge pus or blood and may recur, forming chronic sinuses.	The main symptoms include a noticeable lump formed above the coccyx, which is tender to the touch. Infection may fill the cyst with pus, causing redness, severe pain, and potential discharge of pus or blood from surrounding tissues.
Cause	Mainly caused by hair penetration into the skin, triggering a foreign body reaction leading to inflammation and infection. The formation of sinuses is closely associated with recurrent infections and inflammation.	Typically caused by foreign bodies such as hair and skin debris embedding into subcutaneous tissue, forming a cystic swelling. When infected, the cyst may form an abscess.

Risk Factors

Pilonidal disease has many risk factors;

Gender: Men have a significantly higher risk of pilonidal disease compared to women, possibly due to more body hair and thicker skin in men.
Age: The age group of adolescents to around 30 years is at higher risk because hair growth is more vigorous, and sebaceous gland secretion is more active during this period.
Prolonged sitting: Long periods of sitting, especially when driving, working in an office, or studying, increase the risk of developing the disease.
Lack of exercise: Insufficient physical activity leads to weight gain and increased abdominal pressure, raising the risk.
Dense body hair: Individuals with more body hair are more prone to hair embedding into the skin, causing foreign body reactions, infections, and cysts.
Overweight: Obese individuals have a higher risk because excess weight increases pressure on the buttocks and coccyx area, leading to skin damage and infections.
Genetic factors: Those with family members who have pilonidal disease are at a higher risk, possibly due to genetic factors and similar lifestyle habits.
Poor hygiene: Neglecting cleanliness in the buttocks and coccyx area can lead to follicle infections and the formation of pilonidal cysts.
Oily skin: Oily skin with active sebaceous glands is more prone to clogged follicles, which can develop into pilonidal disease.
Tight clothing: Wearing tight clothing or clothes made of synthetic materials increases friction in the buttocks and coccyx area, causing skin damage and infections.
Hyperhidrosis: Excessive sweating increases skin moisture, making follicles more likely to clog, leading to pilonidal disease.

Diagnosis

Clinical Examination: Healthcare providers first thoroughly inquire about the medical history and perform a physical examination of the affected area. Key symptoms include pain, redness, swelling, and sometimes discharge of pus or blood, typically near the coccyx.
Imaging Studies: In some cases, imaging studies such as ultrasound, MRI, or CT scans may be used to assess the extent of infection and rule out other conditions.

Treatments

Conservative Treatment	Hygiene and Hair Removal: Keeping the affected area clean and free from hair helps to prevent infection. Regular shaving or the use of hair removal creams is recommended. Warm Compresses: Applying warm compresses can alleviate discomfort and promote the drainage of abscesses. Antibiotics: If an infection is present, antibiotics may be prescribed to treat the bacterial infection.
Minimally Invasive Procedures	Incision and Drainage: A minor surgical procedure can be performed for abscesses to drain the pus and reduce inflammation. It is usually an outpatient procedure. Phenol Injection: In some cases, after draining the abscess, a phenol injection is used. This chemical helps to sclerose the cyst, reducing the chances of recurrence.
Surgical Treatment	Excision and Primary Closure: The cyst and affected tissue are surgically removed, and the wound is closed with sutures. This method often has a quicker recovery time but a higher risk of recurrence. Excision and Healing by Secondary Intention: After the cyst is removed, the wound is left open to heal naturally from the inside out. This method reduces the risk of recurrence but requires a more extended healing period and diligent wound care. Flap Surgery: For recurrent or complex pilonidal disease, flap surgery may be performed. It involves reconstructing the area with a flap of skin and subcutaneous tissue to cover the defect and reduce the risk of recurrence.
Laser Treatment	Laser Treatment is an emerging method for treating pilonidal disease. The hair pigment within the cyst or sinus absorbs the laser light, effectively destroying the hair follicles and reducing hair growth, significantly lowering the risk of recurrence. For patients with recurrent or chronic pilonidal cysts, laser therapy can be performed. A specialized laser fibre is inserted into the cyst cavity to destroy the cyst lining and any residual hair or debris. Laser treatment is less invasive than traditional surgical methods and offers advantages such as faster haemostasis, reduced pain, and shorter recovery times.