Answers to Questions about Pilonidal Disease

If you are not sure if you have pilonidal disease or a pilonidal cyst – follow this link for information about the diagnosis of this condition.

Below are some questions about pilonidal disease, and my answers . You will find many differing opinions among patients and doctors. These answers are my findings based on my research and 40 years of surgical training and practice.

It is caused by a "cyst" and removal of the cyst is the treatment.

It is not caused by a cyst, it is the result of a deep cleft between the buttocks. This deep cleft causes irritation in the base of the cleft because it is never open to air. Enlarged pores develop, and sinus tracts begin to grow from the skin down into the fat underneath. Hairs get caught in these tracts, and burrow their way under the skin where they can cause discomfort, or initiate an infection. The configuration of the cleft must be adjusted in order to eradicate this process.

The theory that these “cysts” or “pits” are something that a person is born with, and exist because of a developmental problem in fetal growth has long been disproved. If a physician is telling you this, then they have not recently revisited the literature.

Pilonidal disease only occurs in hairy men.

No, it happens in women with minimal body hair as well, but it is more frequent in men. The hairs that get caught in the pits are loose hairs that get caught in the cleft and find their way into the enlarged pore. Hairs from anywhere on the body can also be shed and find they way into the gluteal cleft, but recent studies show that the hairs are usually from the back of the head. So, even women with very minimal body hair can also have pilonidal cysts. At our clinic 1/3 of the patients are female.

It only occurs in people who sit a lot.

This can occur in people with all kinds of activity levels, including those who are very active and those who are not. Sitting for long periods may make the pilonidal disease become more bothersome – but it does not cause the problem.

It only occurs in obese people.

This is not true either. The vast majority of patients I have seen are of normal weight.

Shaving the area is necessary to prevent problems

While it is possible that shaving the buttocks and gluteal area will decrease the amount of hair that is available to get into the pores, hair that naturally is shed from other areas of your body can find their way into the pores as well. Recent studies, where researchers examined the specific hairs found in cysts, have shown that many of these hairs usually come from the back of the head (71% head, 65% buttocks, 14% low back) . For this reason, I do not feel that local hair removal is a complete solution to pilonidal disease, nor a necessary part of all treatment regimens. I think that as physicians, we have to find solutions that are reasonable for a patient to adopt – and frequent shaving of the torso is burdensome. However, if a patient’s goal is to avoid surgery, or a surgeon who can perform a cleft-lift is not available, diligent hair removal may decrease frequency of infections. But, keep in mind, as mentioned above, the hairs usually come from the back of the head.

Although we do not generally recommend hair removal as a solution to pilonidal disease, nor a necessity after cleft lift surgery, if you feel that you do want to do this, we don’t recommend shaving – but rather recommend using a clipper to keep the hairs short.

It is caused by sitting, trauma, riding a bike, etc.

These activities may make pre-existing, but unrecognized, pilonidal disease suddenly become symptomatic or flare up. But, it does not cause the disease. The disease is caused by the configuration of the cleft.

It can be worsened by wearing tight clothes.

Clothing such as yoga pants, stretch jeans, compression shorts and tights can squeeze the buttocks together in some patients and worsen, or even cause pilonidal disease. More about that here.

An MRI is helpful in defining whether I have pilonidal disease, and determining what operation I will need. My doctor is worried about a bone infection (osteomyelitis).

I don’t agree with this, and have not found expensive MRI’s, CT Scans, or ultrasounds necessary. The visible findings on physical exam and history, coupled with the patient’s symptoms are all that is needed to diagnose pilonidal disease. A cleft-lift procedure, if properly done, will find and remove any tracts and prevent them from coming back. Defining them pre-operatively is not necessary. Osteomyelitis from this is extremely rare, and usually develops in patients with a predisposing disease process, other than just pilonidal disease. Here is more about that subject.

Open excision has the lowest recurrence rate because it removes all the disease.

Actually, it has one of the highest recurrence rates because it does not necessarily change the anatomy of the cleft. It is very frustrating to go through 3-12  months (or more!) of wound care and healing, to have new pilonidal disease develop a few months later. A cleft-lift has the lowest recurrence rate.

Sitting is not allowed for many weeks after pilonidal surgery.

Although some surgeons may restrict sitting after pilonidal surgery, I never do. The weight of sitting is on the pelvic bones, not over the coccyx and sacrum – so there is no significant pressure on the incision. Furthermore, there is no evidence that sitting interferes with blood flow to the surgical site; it may actually be beneficial because it keeps the gluteal crease spread open which promotes healing. Of course, patients need to be gentle with the area and avoid trauma, but I have never had a patient have a healing problem from sitting normally.

If the symptoms are minimal, it is better to just live with the disease because the surgery is painful and difficult.

If a physician is telling you this, then they are not familiar with cleft-lift surgery. The cleft-lift procedure is fairly straightforward, the recovery is usually quick, the recurrence rate is low, and the discomfort is usually less than having a pilonidal infection. However, since other operations for pilonidal disease are problematic – experience with these may have generated the erroneous idea that surgery for pilonidal disease usually fails.  More about the thought processes involved with treating “minimal disease” here.

Topical treatments or antibiotics can cure pilonidal disease.

There are no known creams, lotions, homeopathic remedies, antiseptics, or antibiotics that will make pilonidal disease under the skin resolve. It is possible, with diligent wound care to get the outward openings, such as the sinus tracts or pores, to heal shut temporarily; and antibiotics can make the pain and infection of a flare up subside. But, the disease can still exist under the skin waiting for a time to become symptomatic. The most effective way to promote external healing is to allow air to circulate around the affected skin by placing a dry gauze pad between the buttocks and changing it frequently. Some patients have described temporary success with topical Tea Tree Oil, oregano oil, or MediHoney – which are effective antimicrobials and anti-inflammatory agents. But, they do not address the basic cause of the problem, which is a deep cleft; nor do they address the tunnels and pockets of hair under the skin.

It is not unreasonable to try these topical methods – but it often leads to a disappointing recurrence. Long term use of these topical agents just turns a curable problem into a chronic disease.

Silver nitrate helps wounds heal.

Silver nitrate is a caustic chemical that has very limited usefulness in the treatment of pilonidal disease. It chemically burns and destroys cells. It will not make a wound that isn’t healing suddenly heal. It’s only utility is in situations where there is chronic inflammation, and there is exuberant healing with heaped up granulation tissue coming out of an incision or open area. By destroying the excessive granulation tissue, it can help the skin close and stop the drainage coming from the granulation tissue. Except in this very unusual instance, it is counter-productive to healing and should be avoided. Although I keep silver nitrate applicators in my clinic for other situations, I have never applied it to a patient with pilonidal disease in 35 years. More about silver nitrate here.

A wound VAC is a good solution for healing pilonidal wounds.

A wound VAC (negative pressure wound therapy) is an excellent way to speed up the healing of wounds that normally would heal if given enough time. Unfortunately, pilonidal wounds often will not heal until the gluteal cleft is flattened – and although a wound vac may initially speed up healing, it will not do anything to prevent recurrence of the pilonidal disease. A wound VAC is often a temporary measure that gives the illusion of solving the problem, but sadly does not. It is a cumbersome, time consuming, uncomfortable, expensive, and awkward solution for young active patients. A cleft lift is a much quicker and less painful solution. I do not use VAC devices in my treatment of pilonidal disease.

If you are looking for even more information, you might want to look at my page about Common Misconceptions about The Cleft Lift Procedure.