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    • MAY 10, 2023
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    Pilonidal Carcinoma

    Pilonidal Carcinoma

    Is this something I need to worry about?

    Often patients ask if they need to worry that untreated pilonidal cysts or sinuses will turn into cancer. The short answer is “probably not”. But there are some things to consider, and if this is something that you are concerned about, here are some facts of which you should be aware.

    • The incidence of carcinoma developing from pilonidal disease is very rare. The actual incidence is not really known, but I have not seen a case of this in 30 years.
    • When cancer develops it is usually in a patient who has had untreated pilonidal disease for several decades, typically around 25 years.
    • It is believed that prolonged chronic inflammation predisposes to malignant degeneration. But not all patients with untreated pilonidal disease for 25 years or more will develop cancer – so there may be a genetic predisposition for this to occur.
    • When it turns into cancer, it is a skin cancer (and most often squamous cell carcinoma).
    • Often, the appearance of pilonidal carcinoma is different than the usual findings with pilonidal disease, and your surgeon may suspect it based on physical examination.
    • When we perform a cleft lift, the pilonidal disease is removed and always sent to the lab for examination. If there was a cancer present, it would be identified.

    There are many reasons for a patient to decide to have surgery for symptomatic pilonidal disease, but in most situations any concern regarding the development of cancer should not really be part of that consideration.

    The only times that it should be a factor is if the pilonidal disease has been present for over 20 years, or the physical findings are unusual. A patient should always be evaluated by a physician for a diagnosis, and to make sure that there are no visible abnormalities that could be cancer.

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    • APRIL 6, 2023
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    Are Chatbots any good for researching pilonidal cysts?

    Are Chatbots any good for researching pilonidal cysts?

    A new age of internet search is upon us! In the past, we could search Google, Bing, Yahoo, etc, and these search engines would take us to thousands (if not millions) of web pages discussing the topic we queried. But, now we can just ask the Bing or Google Chatbot a question, and it can distill the information on the internet, and give us a full answer, without forcing us to wade through many web pages to find our specific answer.

    But- does it work?

    I tried some experiments, asking the Bing Chatbot some questions about pilonidal disease, to see how it would answer.

    I asked it: What is the best way to treat pilonidal cysts? The answer it came up with was:

    Pilonidal cysts can be treated with antibiotics, sitz baths, warm compresses, and surgery. The only way to get rid of a pilonidal cyst is through a minor surgical procedure. During this procedure, a doctor will make a cut and drain the cyst. If the infection is severe, you may need surgery. Injections (phenol) can treat and prevent mild and moderate cases of pilonidal cysts.

    Hmmm. It looks like they are confusing pilonidal cysts with an acute pilonidal abscess, for which antibiotics, sitz baths, warm compresses, or surgical drainage is indeed recommended – but it is not the answer to the question. Phenol injections have been tried in the past, but are rarely used at the present time.

    So, I would rate this answer as a complete failure, and quite confusing.

    So, I slightly changed the question to: What is the best way to treat a recurring pilonidal cyst?

    A pilonidal cyst is usually treated in your health care provider’s office. After numbing the area, your health care provider makes a small cut to drain the cysts. If the cyst returns, you may need surgery. If you need surgery, your health care provider numbs the area and removes the cyst through an incision.

    Laser treatment is also an advanced and safe option to get rid of pilonidal sinus for once and for all. It is minimally invasive in nature and requires incisions. Laser treatment for pilonidal cyst takes about only 15 minutes to complete. It is a daycare procedure that enables the patient to return home on the same day of the treatment.

    The chatbot is confusing a pilonidal abscess, pilonidal cyst, and pilonidal sinus again, but it does say that if it comes back surgical removal is appropriate. It also mentions laser treatment, which can be used for a pilonidal sinus. Laser surgery (SiLaC) is a newer treatment with uncertain success rates, but is not an unreasonable suggestion.

    Overall, this answer is confusing and misleading, but a bit better than the first one.

    At this point, I’ve resigned myself to the fact that the Bing Chatbot is not going to give me an answer that makes sense regarding the general treatment of a pilonidal cyst, so I added a fact that requires some additional knowledge, specifically that the best treatment for pilonidal disease requires surgery. I specifically asked: What is the best surgical treatment for a pilonidal cyst?

    There are several surgical options for treating pilonidal disease. One option is the Bascom cleft lift operation, which leaves a closed, sutured wound and has a reported recurrence rate of less than 2%. Another option is laser surgery, which has been reported to have a high success rate.

    It’s important to note that success rates can vary depending on the individual case and the surgeon performing the procedure. It’s best to consult with your healthcare provider to determine which surgical treatment is best for you.

    This is a pretty good answer! But, unfortunately, you have to already know to specifically ask about surgery. I’m glad to see that it didn’t mention open or closed excision at all, since excisional procedures have very high failure rates.

    Finally, I asked it: What operation for pilonidal disease has the best success rate?

    According to a study comparing the cleft lift procedure with wide excision and packing for the treatment of pilonidal disease in adolescents, the cleft lift procedure resulted in primary healing, lower likelihood of recurrent disease, and simplified wound care. Only one cleft lift patient had recurrent disease (2.5%) compared with 7 (20.6%) of 34 excision patients.

    It’s important to note that individual cases may vary and it’s best to consult with your healthcare provider to determine which surgical treatment is best for you.

    Again, I think this is pretty good, but requires not only knowing that surgery is needed, but also knowing that there are multiple options for surgery and that a decision has to be made regarding which one to have.So, these chatbots can provide some good information, but unfortunately a person needs to already know a bit about the subject to get the correct answers, and has to ask leading questions. These answers also had a number of web links as references (which I removed here for clarity) but I was happy to see that as the answers became more accurate, that pilonidal.com was always listed as a reference!

    Of course, this raises the question regarding why the Bing Chatbot knows that the cleft lift is the best operation for pilonidal disease, but many surgeons do not.

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    • APRIL 4, 2023
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    Hyberbaric Therapy for Pilonidal Wounds

    Hyberbaric Therapy for Pilonidal Wounds

    Is hyperbaric therapy a good solution for pilonidal wounds that won’t heal?

    We often see patients who have spent a great amount of time, expense and effort in trying to get wounds to heal after failed pilonidal surgery. One of the treatment modalities that is used at times is hyperbaric oxygen therapy.

    Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized environment. This increases the amount of oxygen in the patient’s bloodstream, and subsequently in their tissues. It is theorized that this plays a beneficial role in wound healing, especially in situations where a patient has a wound in an area with a poor blood supply, and therefore, low tissue oxygen levels (this is called tissue ischemia). Typically, hyperbaric oxygen treatments are around 2-3 hours long. Patients are placed in a compression chamber for that period of time, and a course of treatment is often at least 20 treatments, and may cost $100-$1000/treatment (usually covered by insurance). Smartphones and other electronics are not allowed in the chamber.

    So, you can see that it is not easy, cheap or convenient. The question is whether it is worth it, and the answer has to come from the patient and family. But, here are some facts that may be helpful in deciding if it is a therapy to try:

    • Pilonidal patients are usually young and healthy and tissue ischemia is not usually a problem.
    • The gluteal area has an extremely rich blood supply, so again, ischemia is not a problem.
    • There are few studies that actually demonstrate the effectiveness of hyperbaric oxygen therapy on pilonidal wounds. The few that exist suggest that wound healing may be slightly sped up, but do not demonstrate that it will make a non-healing wound heal.
    • Documenting that a wound initially healed is a very different fact than showing that it stays healed. There are no studies showing that using hyperbaric therapy for a period of time to get a wound to heal will make that healed wound strong and durable, and prevent recurrent pilonidal disease.
    • The reason pilonidal wounds may not heal has to do with their location in the gluteal crease. The environment in the crease is moist, has pressure, promotes bacterial growth, and may be low in oxygen. A treatment for an few hours now and then will not change that in the long run.

    So, is it worth the time and trouble? There certainly is no harm in giving it a try, but it is a lot to go through. In some ways it is similar to the wound VAC device, in that it may give the illusion of healing, but the healing doesn’t last permanently.

    In our opinion a cleft lift is a quicker, easier (and often less expensive) solution that has a much higher success rate (about 95% if the patient has had previous failed surgery). If you contact us and send us photos, we can quickly give you an idea if it is a better solution.

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    • MARCH 29, 2023
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    Suture Reactions

    Suture Reactions

    When I perform a cleft-lift, there are dozens and dozens of sutures holding the flap in place. Sutures hold tissues in position until the body’s natural healing process takes over and normal scar tissue takes their place. This healing process takes six weeks in a well nourished patient.

    In general, we want suture material that completely dissolves, so that there is not any permanent suture material left in the wound. We surgeons have many kinds of dissolving sutures at our disposal, and it has taken me a while to find the suture material that provides the strength needed, but with the least problems. The sutures I use begin losing their strength after 4-6 weeks, but take as long as 6 months to completely dissolve. Unfortunately, there is no suture material that provides strength for six weeks, and then instantly disappears.

    I use a synthetic (man-made) monofilament suture (smooth, single-strand, like a fishing line) which is greenish-blue in color. This type of suture material dissolves over time by the action of enzymes in the tissues.Suture material can cause reactions long after it is done holding things together. These can cause superficial problems manifested by:

    • red bumps
    • areas of drainage
    • areas of bleeding
    • thickening of the scar
    • small wound separations

    In patients with pilonidal disease this can cause a lot of anxiety, as it can easily be confused with recurrence of the pilonidal disease itself. I encourage patients to send me photos of any areas of concern so I can tell them the cause of the visible change. Patients with pre-existing autoimmune diseases (especially those with hidradenitis suppuritiva) seem to be prone to having reactions to suture material. Patients who had a contaminated or infected wound are also prone to these problems, some of which are related to bacteria attaching to the suture material and then causing problems later.

    These suture-related problems are always self-limiting – because the suture material eventually dissolves. If there is an area of drainage, it is OK to clean it with peroxide or soap and water, and put a dry dressing on it. If the area is down near the anus, putting a piece of gauze between the cheeks, as you may have done initially post-op is a good idea until it stops draining.

    Below are a few photos of what this can look like. These patients went on to heal without any kind of surgical intervention. Typically, I recommend Vitamin C Serum to treat these which seems to speed up healing.Here are two examples of suture reactions. You can see bumps right where sutures were placed during the operation.

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