If you are trying to deal with this without surgery.
When patients come to me for treatment of pilonidal disease, they usually have already investigated the problem and are interested in a surgical approach. But, not everybody is like this. Some patients prefer to avoid surgery, and want to know what they can do to either cure the disease or minimize the symptoms without an operation.
Every patient’s situation is different, and some people are going to have many, many painful problems from this, and others will just have one or two episodes before the process becomes asymptomatic. Sometimes, it is easy to predict that someone is going to have problems because of their basic anatomy and age: a deep cleft in a hirsute young person is a setup for future problems. Other times, it is not so easy to predict. If you have very minimal disease, and are struggling with the decision of whether or not to consider surgery, you might want to look at the discussion on this page: Pilonidal Disease with Minimal Symptoms.
However, there are some strategies that can be used to try to decrease the number of painful infections and try to keep this process at bay; keeping in mind that this can turn a solvable problem (solved with a cleft-lift) into a chronic disease that requires frequent or constant attention.
Here are some things to try:
Keep the area as clean as possible by showering or bathing daily with a mild antibacterial soap (Hibiclens is a good choice). Thoroughly dry the area in the cleft afterwards. Some patients recommend soaking in an epsom salts bath. This may be helpful in washing away debris, killing bacteria, and decreasing swelling around the pores, although whether the addition of the epsom salts to the bathwater is beneficial is controversial.
Patients who have enlarged pores in the midline of the gluteal crease are the ones who are at risk of developing a painful pilonidal abscess. As long as these pores are open and able to drain symptoms may be minimal. But, if the area is traumatized by sitting directly on the area, or bouncing in a vehicle, or similar situations – the pore may swell shut, bacteria are trapped under the skin, and an abscess develops. Often patients note that an abscess develops after a situation like this. The trauma to the area doesn’t cause the pilonidal cyst, but may cause it to become infected.
Minimizing the amount of hair available to get caught in the pores can be helpful. Any method that is not irritating to the skin is acceptable, including depilatory agents, shaving, clipping, or laser hair removal. However, this is not a perfect solution, since hairs from anywhere on the body can find their way into the crease, not just the hairs growing locally. In fact, recent studies have shown that most of the hairs in pilonidal cysts come from the back of the head – not the hair on the buttocks and low back. I do not recommend hair removal after a cleft-lift, because it is no longer necessary. You can read about some of the latest information about hair in this blog post.
There are many anecdotal reports of patients getting relief by using a topical antiseptic in the gluteal crease. This may be helpful in minimizing the frequency of infections, but there are no good studies to confirm this. Most important, is that the antiseptic dry completely after application and not irritate the skin. If it irritates the skin, it may cause swelling of the pores and cause infection rather than prevent it. Common homeopathic antiseptics are tea tree oil, garlic, fenugreek, turmeric, coconut oil, Epsom salts, castor oil, grape seed oil, oregano oil, CBD oil, vinegar, baking soda, Manuka honey, OXY pads, and aloe vera. Again, I must stress that this may minimize frequency of infection, but not cure the problem, and I do not recommend any of these treatments. I would avoid antibiotic ointments, because ointments keep the area chronically moist, which is not healthy for the skin.
When topical treatments are recommended it is often not specified that some of these are only for use on intact skin, others are to help an abscess drain, and others are for open wounds. These remedies are often given a blanket recommendation for all pilonidal disease which is not appropriate, and at times not safe. (For example, tea tree oil is to be put on intact skin, while Manuka honey is to help an open wound heal.)
Placing a gauze pad between the buttock cheeks so that air can circulate may be one of the best strategies. This will keep the skin in the cleft dry, allow the pores to drain, and disrupt the pressure phenomenon that draws hairs into the pores. The least expensive, plain, woven, “gauze” pads at the pharmacy are the best.
Dealing with an abscess:
If a patient can tell that an abscess is forming by the onset of pain and pressure next to or in the gluteal crease, I recommend going to see an experienced surgeon for drainage. If this is not an option, or you want to see if you can get it to drain on its own, the next best approach is warm moist heat, for about 15 min at a time, about 4x per day. Hopefully, this will bring it to a head, so it drains. Unfortunately, some of these abscesses are so deep that this take a very long time, or doesn’t work at all – so having a surgeon look at this is preferable.
If you search the internet, you will find many people who will strongly recommend one homeopathic treatment or another based on their personal experience. Many of these are reasonable and are safe for experimentation. But, sometimes cause and effect are erroneously attributed to one another, especially since this is a disease process that has symptoms that come and go on their own. This reminds me of a very old joke:
Two strangers were sitting next to each other on a train going across the country. The man next to the window would periodically tear a small piece of paper off of a pad and toss it out the window. After an hour of watching this, the other passenger asked him why he was doing this. His reply was:
“To keep the elephants away from the train.”
“But there are no elephants within 3000 miles”.
“See! It works!”
Someone’s success with a particular remedy may not actually be related to that remedy. So, be careful about what you read and be skeptical about accepting the conclusions of other individuals! If there are no controlled studies to back the claims up, take them with an appropriate dose of skepticism.