Pilonidal Disease Practice Points an Update

CLINICAL

Pilonidal disease practice points An update

Kay Tai Choy, Havish Srinath PILONIDAL DISEASE is an inflammatory lining is characterised by haemosiderin- condition that typically affects the laden macrophages and sometimes even sacrococcygeal fold. The term ‘pilonidal’ foreign body giant cells, reflecting the Background 5 Chronic pilonidal disease is a common is derived from the Latin words for hair chronic inflammatory picture at play. debilitating condition often seen in (pilus) and nest (nidus), implying a nest of Surprisingly, only 50–75% of these cavities general practice. It is a cause of hair. The majority of cases are localised have been found to contain hair shafts.4 considerable morbidity and social to the buttock and gluteal region, with embarrassment, but recent few reported cases involving other parts developments in treatment options of the body such as on the scalp, axilla, Clinical presentation provide promising solutions to groin or in between the fingers of sheep Asymptomatic sinus this problem. shearers/dog groomers.1,2 Common Some patients may be concerned about the Objectives presentations range from acute abscesses presence of asymptomatic pilonidal sinus This article recaps pilonidal sinus to extensive chronic infection or a sinus pits. This should be treated by reassurance development and presentation, details formation (a blind epithelial tract, lined and hygiene,8 because the disease often methods of treatment in the primary by granulation tissue).1 In particular, the dissipates as the patient passes the fourth care setting and explores new specialist management options chronic discharging sinus (pilonidal sinus), decade of life. available in Australia. characterised by painless chronic waxing and waning drainage, has been a challenge Acute pilonidal abscess Discussion for many primary physicians in Australia.3 During an acute flare-up, patients usually As a chronic condition, the devastation of recurrence with further pain, Among the adult population in the complain of acute pain, with swelling, embarrassment and time off work – Western world, the estimated incidence erythema, and a tender lump in or near added to the prospect of more surgery is 26 per 100,000 people, with incidence the natal cleft. Localised source control is – is still common for patients with peaking in the second and third decades of advocated as the mainstay of treatment. chronic pilonidal disease. This can be life. Men are twice as commonly affected Current options include needle aspiration, avoided with correct management and as women.1 Other risk factors include drainage without curettage of the cavity, timely counselling regarding surgical increased body mass index, coarse hair or primary drainage and curettage of the options available. and a deep natal cleft.4,5 cavity to remove any hair follicles or debris. The value of antibiotic therapy in an acute pilonidal abscess has not been Aetiology/pathology clearly established in the absence of The aetiology of pilonidal sinus is still a immunodeficiency or concurrent systemic matter of controversy, but the three most illness.9 However, should there be widely accepted theories include the associated cellulitis around the abscess, a foreign body response theory as outlined course of antibiotics is recommended. This by Karydakis,6 the Bascom hypothesis of is commonly penicillin, with flucloxacillin ‘midline pits’7 and the Stelzner theory of the most widely prescribed.10 retention dermatopathy.7 The common point shared by these theories is that Chronic pilonidal sinus chronic retention of keratin/debris in the Patients usually present with intermittent natal cleft and its associated inflammatory pain, swelling and discharge at the response cause pilonidal disease.4 Over base of the spine, without significant time, this results in a pattern of waxing constitutional symptoms. There is often a and waning inflammation. history of repeat abscesses that either drain Evaluation of pilonidal sinuses has spontaneously or have been drained with shown that the cystic cavities within the incisions away from the midline. sinus branch outwards and are lined by In this group of patients, various surgical chronic granulation tissue. The sinus’ techniques can be considered to treat

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the chronic symptomatic pilonidal sinus. flaps in the treatment of pilonidal sinus, used to similar effect. Thereafter, a lateral They comprise radical excision, deroofing, the Bascom and Limberg techniques are incision is made to allow open exploration debridement of the sinus tract followed also used today. A direct comparison is of the pilonidal cavity and removal of by primary flap coverage (which could be shown in Table 1. granulation tissue/debris material. This attempted in the day surgery by the primary allows secondary hair pits to be debrided/ physician with surgical experience), as well Karydakis method cleaned out. Finally, to lateralise the scar as newer methods including endoscopic In the Karydakis method, the sinus is and reduce the depth of the natal cleft, pilonidal sinus treatment (EPSiT). A brief completely excised down to the midline the skin on the opposite side of the cleft review of each is provided below to outline sacral fascia. All affected tissue is removed is mobilised to lateralise the suture line. the various treatment options available today. and the area carefully debrided.6 To achieve coverage, a covering flap consisting Limberg flap procedure of skin, dermis and the underlying fat is Limberg et al have also advocated excision Surgical techniques then created by undercutting the medial of the affected sinus and surrounding Traditional techniques have aimed to edge. This flap is then lateralised across tissue.12 However, a rhomboid shaped remove the area of chronic inflammation the midline. The wound is closed in layers, incision is purported to allow the flap of as well as any potential remaining nidus producing a lateral, vertical scar. skin lateral to the incision to be raised and of infection, with healing achieved via transposed medially to flatten out the natal secondary intention or primary coverage Bascom ‘cleft lift’ cleft, producing a Z-shaped scar. with surrounding tissue flaps. The feature The Bascom lift was developed as a less of the flap is to create a wound off the invasive technique with the additional EPSiT midline to allow healing and also to aim of removing secondary hair follicles In order to overcome the disadvantages decrease the recurrence of the disease. to break the cycle of inflammation.11 of the open techniques, the viability of The following three techniques Hair follicles are first excised with mini EPSiT has been explored over the last have been shown to be effective in the incisions of <5 mm. The use of punch few years. First developed by Meineiro, treatment of pilonidal sinus. While biopsies to excise the core of tissue this process uses a fistuloscope, which Karydakis pioneered the use of tissue around the hair follicle has also been is passed through the sinus tract to

Table 1. Surgical techniques to treat chronic pilonidal disease

Procedures Pros Cons

Lay open of sinus Simple procedure. High recurrence rates. Quickest procedure to perform. Healing by secondary intention requires an extended period of wound care.

Flap procedure 1: Karydakis Most successful procedure with potentially lowest Original method had complaints of significant recurrence rates, found to be as low as 1% by post‑operative pain. 6 Karydakis himself. Post-operative complications include infection Other studies have reported an equally impressive and seroma formation. 15 recurrence rate of 3–5%. Flap dehiscence implies healing by secondary intention.

Flap procedure 2: Bascom Healing time is shortest out of the three flap Recurrence rates of approximately 15%.7 procedures, at an average of 3.5 weeks.7 Least amount of post-operative pain when compared with other flap procedures.

Flap procedure 3: Limberg Lower rates of post-operative pain, infection and Bigger cut and scar, hence poorer cosmesis. seroma formation when compared with the original Procedurally takes a longer time in a prone 16 Karydakis method. position than the other flap procedures.

Endoscopic pilonidal sinus Benefits of laparoscopic surgery. Lack of long-term data given its novelty. treatment (EPSit) The aesthetic result appears to be good, as opposed Given there is no excision and flattening of the to traditional lay open techniques. natal cleft, there are concerns regarding long- The reduced healing time (2–3 weeks) translates to a term recurrence with this technique. shorter recovery time and more prompt return to work. There is no need for painful packing and dressing changes as per the traditional techniques. Recurrence rates are acceptably low at 5%.4 The procedure may be repeated.

allow direct visualisation in a minimally hair removal. However, patients who 7. Bascom J. Pilonidal disease: Origin from follicles of hairs and results of follicle removal as treatment. 4 invasive manner. removed their hair via shaving or hair Surgery 1980;87(5):567–72. Visual exploration of the pilonidal removal cream had greater rates of 8. Armstrong JH, Barcia PJ. Pilonidal sinus disease: The sinus, as well as any possible fistula recurrence, thought to be due to skin conservative approach. Arch Surg 1994;129(9):914–17. 9. Humphries AE, Duncan JE. Evaluation and tracts or abscess cavities, allows trauma from shaving and possibly the management of pilonidal disease. Surg Clin identification of all hair follicles lack of compliance in the long run.14 North Am 2010;90(1):113–24. doi: 10.1016/j. and debris. Subsequently, careful Nonetheless, good hygiene is still suc.2009.09.006. 10. Khanna A, Rombeau JL. Pilonidal disease. Clin Colon debridement of the granulation tissue the mainstay of secondary prevention Rectal Surg 2011;24(1):46–53. doi: 10.1055/s-0031- can be done under visualisation, allowing and highly important to stress on 1272823. a targeted but complete removal of the individuals suffering from pilonidal 11. Bascom J, Bascom T. Utility of the cleft lift procedure in refractory pilonidal disease. Am chronically inflamed area. This targeted disease. J Surg 2007;193(5):606–09. doi: 10.1016/j. approach reduces the risk of unnecessary amjsurg.2007.01.008. damage to surrounding tissue structures 12. Wolfe SA. Alexander A. Limberg, M.D. 1894–1974. Plast Reconstr Surg 1975;56(2):239–40. and thereby reduces the associated Key points 13. Giarratano G, Toscana C, Shalaby M, Buonomo O, post-operative inflammation. • Good hygiene is the main component Petrella G, Sileri P. Endoscopic pilonidal sinus In short, EPSiT is thought to build on of secondary prevention. Hair removal treatment: Long-term results of a prospective series. JSLS 2017;21(3). doi: 10.4293/JSLS.2017.00043. the Bascom principle of removing hair via laser treatment can also be 14. Pronk A, Eppink L, Smakman N, Furnee E. The effect and debris, but with an endoscopic focus recommended. of hair removal after surgery for sacrococcygeal to improve recovery time and reduce Acute infections require urgent local pilonidal sinus disease: A systematic review of • the literature. Tech Coloproctol 2018:22(1):7–14. 8 morbidity. control of sepsis. This includes needle doi: 10.1007/s10151-017-1722-9. However, there is still a lack of long-term aspiration or incision and drainage. 15. Kitchen PR. Pilonidal sinus: Experience with the data in comparison to the established • There are many surgical options Karydakis flap. Br J Surg 1996;83(10):1452–55. 16. Bali İ, Aziret M, Sözen S, et al. Effectiveness of traditional techniques. Its reported success available for chronic pilonidal sinus Limberg and Karydakis flap in recurrent pilonidal rate of 92% from recent small population disease. These range from traditional sinus disease. Clinics (Sao Paulo) 2015;70(5):350–55. studies still pales in comparison to the open methods of removal of sinus to doi: 10.6061/clinics/2015(05)08. success rates of open flap procedures.13 EPSiT, which has shown promising results to date.

Follow-up and secondary Authors prevention Kay Tai Choy MBBS, BHlthSc, Senior House Officer, Ipswich Hospital, Qld. [email protected] Dressing Havish Srinath MBBS, BCom-ACST, BAppFin, SET 4 Careful wound care to ensure optimal Surgical Registrar, Ipswich Hospital, Qld conditions for healing is important. Competing interests: None. Vacuum dressings applied after laying Funding: None. open the sinuses have not been shown Provenance and peer review: Not commissioned, externally peer reviewed. to be significantly better than simple dressings,9,10 but may be considered on References a case-by-case basis after taking into 1. McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for account factors such as patient and pilonidal sinus: Systematic review and meta- practitioner preference.10 analysis. BMJ 2008;336(7649):868–71. doi: 10.1136/ bmj.39517.808160.BE. 2. Çiftci F, Abdurrahman I. A different disease: Hair removal Extrasacrococcygeal pilonidal sinuses Hair removal in pilonidal disease has etiopathogenesis. Int J Clin Exp Med been a topic of controversy. On the 2015;8(7):11567–71. 3. Kitchen P. Pilonidal sinus: Management in basis of previous understanding that the primary care setting. Aust Fam Physician pilonidal disease was a disease of 2010;39(6):372–75. misgrown hair follicles, it followed 4. Meinero P, Stazi A, Carbone A, Fasolini F, Regusci L, La Torre M. Endoscopic pilonidal sinus treatment: naturally that hair removal was thought A prospective multicentre trial. Colorectal Dis to be a mainstay of treatment. 2016;18(5):O164–70. doi: 10.1111/codi.13322. Today, there is only support in the 5. Chintapatla S, Safarani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: Historical literature for hair removal with laser review, pathological insight and surgical options. treatment.14 It has been shown that Tech Coloproctol 2003;7(1):3–8. doi: 10.1007/ s101510300001. a significantly reduced recurrence 6. Karydakis GE. Easy and successful treatment of rate was recorded in these patients pilonidal sinus after explanation of its causative in comparison to patients with no process. Aust N Z J Surg 1992;62(5):385–89. correspondence [email protected]