Pilonidal Disease

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Pilonidal disease, also known as pilonidal cyst or pilonidal sinus, is a condition that affects the skin at the base of the tailbone, known as the coccyx. This ailment occurs when a cyst or abscess forms in this small dimple located just above the cleft of the buttocks. The name "pilonidal" originates from the Latin words "pilus" (hair) and "nidus" (nest), precisely describing the characteristic feature of the disease. Pilonidal cysts occur when loose hairs, dirt, and debris get trapped in the skin's pores, creating a small pocket or sinus. Over time, these trapped materials cause an infection and inflammation, leading to the development of a cyst or abscess.

Hair and Follicular Factors: One of the primary factors associated with pilonidal disease is hair growth and its subsequent effects on the skin. This condition often affects young, hairy individuals, and it is commonly believed that hair penetrating the skin and triggering an inflammatory response is a key contributor. Friction due to constant movement, such as sitting or exercise, along with excessive sweating, can also contribute to hair follicles becoming blocked, leading to the development of a pilonidal cyst.
Congenital Factors: Pilonidal disease has been linked to certain congenital factors, suggesting a genetic predisposition. Some studies have identified a familial clustering of cases, indicating a hereditary influence on the development of the condition. Additionally, certain anatomical features, such as a deep natal cleft, excess skin, or a dimple in the sacro-coccygeal area, may also contribute to the formation of a pilonidal cyst.
Obesity and Sedentary Lifestyle: Obesity and a sedentary lifestyle have been associated with an increased risk of developing pilonidal disease. The excess weight puts additional pressure on the coccygeal region, leading to increased friction and inflammation. Moreover, a sedentary lifestyle, combined with prolonged sitting, can further exacerbate the condition.
Poor Hygiene: Maintaining proper hygiene in the sacro-coccygeal area is crucial for preventing pilonidal disease. Poor hygiene, specifically inadequate cleaning of the area, may lead to the accumulation of sweat, dirt, and bacteria, which can contribute to the blockage of hair follicles and the development of a cyst.
Trauma and Injury: Trauma and repetitive injury to the coccygeal region are also considered potential triggers for pilonidal disease. Direct trauma or pressure, such as falls or bike riding, can damage hair follicles or cause hair to penetrate the skin, initiating the cyst formation process.

The exact cause of Pilonidal disease is not clear, but it is believed to arise from a combination of hereditary, anatomical, and environmental factors. The condition is more common in young males, and it is thought that the presence of certain hair follicles in the midline of the natal cleft predisposes individuals to the development of Pilonidal disease.
The pathophysiology begins with the presence of loose hairs, sweat, and debris in the natal cleft. These materials find their way into the hair follicles, causing irritation and inflammation. This irritation triggers an immune response, leading to the formation of a cyst or abscess.
As the condition progresses, the cyst or abscess may become infected, leading to the formation of a sinus tract. This tract extends deeper into the subcutaneous tissue and may connect with the underlying structures, such as the coccyx or sacrum. The presence of the sinus tract creates a pathway for persistent drainage, allowing the cycle of infection and inflammation to continue.
The accumulation of hair, dead skin cells, and debris within the cyst or sinus tract further perpetuates the inflammatory process. This chronic inflammation leads to the development of granulation tissue, which further narrows the sinus tract and makes it difficult for the area to heal. The ongoing inflammation also contributes to the formation of scar tissue, which can result in the recurrence of Pilonidal disease even after surgical intervention.
The pathophysiology of Pilonidal disease is also influenced by factors such as poor hygiene, excessive sweating, and prolonged sitting or pressure on the coccygeal region. These factors can worsen the inflammation, increase the risk of infection, and contribute to the chronicity of the condition.

1. Genetics.
2. Obesity.
3. Excessive body hair.
4. Sedentary lifestyle.
5. Poor hygiene.
6. Trauma or injury.
7. Young age and male gender: Pilonidal disease is more commonly seen in younger individuals, typically between the ages of 15 and 30. Additionally, the condition is more prevalent in males than females. Hormonal and anatomical differences between genders may play a role in this gender disparity.

1. Pain and swelling in the lower back: One of the primary signs of pilonidal disease is the presence of pain and swelling in the lower back near the tailbone or coccyx. The discomfort may range from mild to severe, and it can worsen while sitting or during physical activities.
2. Redness and tenderness: The affected area may appear red and feel tender to the touch. The skin around the pilonidal cyst can become inflamed and irritated, causing further discomfort.
3. Formation of a cyst or abscess: Pilonidal disease is characterised by the development of a cyst or abscess. A cyst is a sac filled with fluid, while an abscess forms when the cyst becomes infected. These can often be felt as a small lump or bump in the affected area.
4. Drainage of pus or blood: In some cases, the pilonidal cyst may start to drain pus or blood. This drainage can have a foul smell and may be accompanied by a discharge of hair and debris from the cyst.
5. Painful or difficult movement: Activities that involve sitting for prolonged periods or putting pressure on the lower back region can make the pain intensify. Movement, especially bending or stretching, can become painful and difficult.
6. Fever and general malaise: If the cyst becomes infected, it can lead to systemic symptoms such as fever, fatigue, and a general feeling of being unwell. These symptoms indicate a more severe infection and should not be ignored.

• History and physical examination: A PA will visually inspect the affected area and examine any visible signs of infection or abscess. They may also evaluate the patient's medical history to determine if they have any risk factors or previous episodes of pilonidal disease.

• Imaging techniques (not routinely required):

• Ultrasound

• Magnetic resonance imaging (MRI)

• Swab sample

1. Conservative Management:
In mild cases or when the infection is not severe, conservative management can be attempted. This approach aims to alleviate symptoms, promote healing, and prevent recurrence. Some conservative management strategies include:
a. Pain relief: Over-the-counter analgesics like paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to relieve pain and discomfort.
b. Warm compresses: Applying warm compresses to the affected area can help reduce pain, promote drainage, and facilitate healing.
c. Good hygiene practices: Thoroughly cleaning the area regularly with mild soap and water can help prevent infection and keep the area clean.
d. Hair removal: Shaving or hair removal techniques, such as laser hair removal, can help reduce the risk of hair follicle recurrence and subsequent infection.
e. Topical treatments: The application of topical antibiotic ointments or creams such as fusidic acid, may be recommended to prevent infection and promote healing.

2. Surgical Intervention:
In cases where conservative management fails to provide relief or the disease becomes recurrent or chronic, surgical intervention may be necessary. Surgical procedures for Pilonidal disease are aimed at removing the cyst or sinus tracts, and the choice of procedure depends on the severity of the disease.
3. Postoperative Care and Prevention:
After surgical intervention, proper postoperative care is vital to prevent complications and recurrence.

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