Pilonidal Disease: Can I Avoid Surgery?

Will this go away by itself? Is it manageable with non-surgical care?

This is a commonly asked question. Although I am a surgeon, I realize that surgery is not for everyone, and nobody is really excited about having an operation if there is another option. Drainage of a painful, infected, abscess (lancing, I&D) is often an emergency and is very obviously necessary, other operations are elective – meaning that a patient has a chance to think about it, weigh the pros and cons, and decide if that is the route they want to proceed.

The decision is easy if the pilonidal disease is painful, embarrassing, disruptive and depressing, and it’s clearly time to do something about it. On the other hand, for other patients surgery is not really the route they want to go. There can be various reasons for this:

  • The symptoms aren’t that bad.
  • Their philosophy that surgery is only a last resort.
  • Financial considerations.
  • Concern regarding the cosmetic change.
  • General fear of surgery and hospitals.
  • Lack of a qualified specialist nearby.

These are all reasons to step back and see if there is a non-surgical approach that will work. It is a rare situation in which pilonidal disease becomes life-threatening. For various reasons, there isn’t very robust data regarding the recurrence rate of pilonidal problems. So, I can’t really tell you that if you had one abscess, what the chances are that you will have another. In a specific situation, if I can evaluate the anatomy, I may be able to predict whether future problems are expected or not. But, if you are not seeing a pilonidal specialist, it will be hard for you to come to any conclusion on your own.

These are situations where future problems are very likely:

  • Multiple, enlarged midline pores or actual open wounds.
  • A very deep gluteal cleft. Sometimes this is apparent, because it takes some strength to spread the buttocks apart to see the base. Or, in other situations, the crease seems to open up easily when prone, but folds when standing. Brownish discoloration (hyperpigmentation) of the skin on either side of the cleft is a clue that this is a problem.
  • Multiple abscesses.
  • The presence of a sinus.

Sometimes after an abscess has been drained, there are no visible abnormalities. This is the kind of situation where it is not clear how much a problem it will be in the future. This web page discusses that situation.

But, if you are dealing with any of the situations described above, it is possible to get along without surgery, but the pilonidal disease is going to be an intermittent long term problem and, contrary to some rumors, will not just disappear after age 40.

Diligent attempts at hygiene, antiseptics, dressings and at times antibiotics may help minimize symptoms, but most likely won’t completely eradicate the problem. A discussion of home remedies can be found here. However, if a patient’s issue is that surgery is not feasible now because of finances or other obligations, some of these home remedies may make delay less painful.

In general my recommendation is that the best approach is to proceed with surgery at some point, and the sooner this is treated, the sooner patients can get on with their lives. I believe the cleft-lift operation by an experienced pilonidal surgeon is the best combination of high success rate coupled with ease of recovery. Contact us if this is something you would like to explore.

Does Pilonidal Disease Go Away After Age 40?

Can I just wait, and it will disappear?

Although it is unusual to start getting new pilonidal disease after age 40, preexisting pilonidal problems often will not go away if they have been untreated. The reason it is rare for pilonidal disease to start as one gets older, is that the gluteal cleft naturally opens up and widens as we age, and the cleft is less deep, and sharp. However, lingering sinus tracts and cysts may still be present and cause problems. So, if you have an untreated sinus tract or cyst, it will not suddenly disappear with age, and may be a problem at any time, even after age 40.

Trauma to the gluteal area may cause it to suddenly act up after years of being asymptomatic. Also, especially in women, starting a new habit of wearing tight stretch pants, can deepen the gluteal crease and start new pilonidal disease even after age 40.

We have seen patients as old as 70 with pilonidal disease that continues to be symptomatic.

So, although it is true that pilonidal disease becomes less and less of a problem as one ages, it is not something that you can rely on to make your pilonidal problems disappear.

Facts about hair and pilonidal disease

Some of the first research on the subject

The term “pilonidal” means “nest of hair”. We know that pilonidal cysts contain loose hairs, but until recently there has not been much research done on what kind of hairs are in the cysts, and why one patient develops pilonidal disease and another does not. Here are some of the more recent facts found by researchers in Germany:

  • Stiffer hairs have more of a tendency to get in these cysts than softer hair.
  • Most of the hairs in a pilonidal cyst come from the back of the head.
  • Hair on the back of the head is stiffer than the hair in the gluteal crease, possibly explaining why hair from the head is more common in cysts.
  • Patients who sweat more have LESS incidence of pilonidal disease than the opposite counterparts. Wet hairs are less stiff, and this may explain why.
  • Most of the hairs in a cyst are found to be short and have sharp ends and no roots.
  • In spite of the usual precautions a barber takes to keep hair from from falling down a customer’s back, cut hairs are immediately found at the level of the low back after a haircut.
  • I have not seen any evidence that showering is a critical time, and that it matters if you rinse your hair forward or back.

This information is all very new, and it’s significance remains to be seen. But, it does suggest that the time after a haircut may be critical in the penetration of pilonidal pits by sharp, stiff hairs, and an immediate shower is a good idea.