Pilonidalsine L05.9

Author: Prof. Dr. med. Peter Altmeyer

Co-Autor: Dr. med. Bernhard Hofer

All authors of this article

Last updated on: 29.10.2020

Dieser Artikel auf Deutsch

Synonym(s)

coccygeal fistula; Coccygeal Fistula; Coccyx cyst; Coccyx fistula; Hair fistula; Hair nest dimples; jeep disease; Jeep driver's disease; pilonidal abscess; Pilonidal cyst; Pilonidal fistula; pilonidal sinus; pilonidal sinus (engl.); Sacraldermoid; sacral fistula; Sacrococcygeal pilonidal sinus; trichogenic foreign body granuloma

History
This section has been translated automatically.

Mayo, 1833; Hodges, 1880

Definition
This section has been translated automatically.

Acute or chronic inflammation in subcutaneous fatty tissue, starting from the midline of the sacrum (pilus = hair; nidus = nest). A distinction is made between asymptomatic, acute abscessing and chronic forms. Basically pilonidalsinus can also occur in other body regions, such as umbilical and interdigital in hairdressers as trichogenic foreign body granulomas.

Occurrence/Epidemiology
This section has been translated automatically.

Mostly occurring in Caucasians. Asians are practically not affected. The incidence is about 20/100.000 inhabitants.

Etiopathogenesis
This section has been translated automatically.

Acquired, multifactorial disease with questionable genetic disposition. Probably, rubbing movements of the nates lead to the impaling of hairs into the opposite skin down to the subcutaneous fatty tissue with subsequent development of a chronic, non-healing foreign body granuloma.

An analogous mechanism is found with the so-called hairdresser's granuloma (impaling of hair) or with the milker's granuloma.

Pilonidalsinus in chronic inflammatory follicular processes, especially in acne inversa and hidradenitis suppurativa, receive a different etiological evaluation.

Manifestation
This section has been translated automatically.

Mostly occurring in young, very hairy men with predominantly sedentary occupation (car drivers, motorcyclists). Men are 2-4 times more frequently affected than women. Occurrence in the context of acne tetrade possible.

Localization
This section has been translated automatically.

Preferably sacro-iliac localization. Comparable clinical pictures are found interdigitally in hairdressers. Occurrence is also possible in other locations (rare): axillae, neck, finger gaps, navel, penis.

Clinical features
This section has been translated automatically.

No complaints in the inflammation-free stage. In the Rima ani, one or more, possibly small fistula openings can be seen, often with ingrown hairs. Tendency to extensive, persistent, abscessing inflammation due to chronic friction and maceration (redness, fluctuation, severe pain, possibly extensive, fox-like fistulations with secondary openings). In the chronic stage, patients suffer from serous malodorous secretions from the sinus, which considerably restrict everyday life.

Histology
This section has been translated automatically.

Pseudoepitheliomatous epidermal hyperplasia with formation of ducts. Possible abscesses around hair fragments with giant foreign body cells.

Differential diagnosis
This section has been translated automatically.

Complication(s)
This section has been translated automatically.

After a longer period of existence a malignant degeneration is possible (predominantly squamous cell carcinoma).

Therapy
This section has been translated automatically.

Conservative forms of therapy have not proven to be curative (Melnik B et al. 2018).

External therapy
This section has been translated automatically.

In the acutely inflammatory stage, anti-inflammatory local therapy, usually with disinfectant baths (e.g. quinolinol 1:1000 or R042, Kamillosan, Braunovidon Lsg.) and ointment dressings (e.g. Furacin-Sol).

Operative therapie
This section has been translated automatically.

The incision is the method of choice for acute abscesses. The optimal location of the incision on the apex of the abscess cavity can be determined by palpation ("doughy dent") and sonography. Intradermal local anaesthesia is preferable to icing in terms of analgesia and avoidance of CFCs. Dermatological biopsy punches with a diameter of 6 mm are suitable for making the incision. The circular canopy thus created usually allows for tamponade-free follow-up treatment.

The radical excision should not yet be performed at this stage because of the high recurrence rate. After the inflammation has subsided, complete excision of the foci (en bloc excision) with subsequent secondary healing is considered standard. Routine excision down to the sacral fascia must be avoided at all costs, since it often causes pain that is resistant to therapy despite recurrence-free healing of the wound.

Primary openings to the side of the midline (off-midline pits), lateral passages and ramifications are untypical of pilonidal fistulas and suggest an inverse acne with a correspondingly less favourable prognosis. Experience shows that the granulation and epithelization phase lasts at least 8 weeks, but can last up to a year depending on the size.

In the inflammation-free interval, operative rehabilitation, if necessary after previous fistula presentation. Generous excision of the pilonidal sinus and all fistulas up to the sacrococygeal fascia. Subsequently secondary healing of the wound.

In order to ensure granulation from the depths, the use of a special pouring procedure, e.g. Cavi-Care, has proven to be effective. The deep wound is poured out with the two-component plastic and the resulting plug is fixed with a self-adhesive foil. This tamponade must be cleaned daily and placed back into the cavi-care. After about 8 days the tamponade must be poured again, as the wound cavity is rapidly shrinking.

As an alternative to secondary healing, the wound can be treated primarily with sutures or by plastic reconstructive surgery.

Note: The lowest recurrence rate of 0-13% is said to be excisions with secondary wound healing. However, a review by Iesalnieks et al (Lesalnieks I et al. 2019) indicates a recurrence rate of up to 57%. In primary surgery, recurrence rates in plastic reconstruction according to Karydakis < 5 % are realistic.

Progression/forecast
This section has been translated automatically.

There is no spontaneous healing. An asymptomatic pilonidal sinus persists for life, but can also acutely change into the abscessing form and then into the chronic stage.

Prophylaxis
This section has been translated automatically.

After the wound has healed, improved personal hygiene is recommended in addition to consistent permanent depilation. It has proven to be effective to remove the hairs from the anogenital region by means of laser depilation.

Naturopathy
This section has been translated automatically.

Irrigation with diluted calendula essence has proven to be effective for disinfecting the deep wound cavity. This leads to a sufficient reduction of germs even in the case of multi-resistant germs.

Note(s)
This section has been translated automatically.

Incorrect synonyms for the disease are the terms coccygeal moid, sacraldermoid, dermoid cyst, coccygeal fistula and raphefiste.

A generally accepted classification for the severity of pilonidal sinus is still missing (Beal EM et al. 2019).

Literature
This section has been translated automatically.

  1. Beal EM et al (2019) A systematic review of classification systems for pilonidal sinus.
  2. Tech Coloproctol doi: 10.1007/s10151-019-01988-x.
  3. Bradley L (2010) Pilonidal sinus disease: a review. Part one.
  4. J Wound Care 19:504-508.
  5. De Martino C (2011) Squamous-cell carcinoma and pilonidal sinus disease. Case report and review of literature. Ann Ital Chir 82:511-514.
  6. Hegele A et al (2003) Reconstructive surgical therapy of infected pilonidal sinus. Surgeon 74: 749-752
  7. Hodges RU (1880) Pilonidal sinus. Boston Med Surg J 103: 485
  8. Karydakis G (1992) Easy and successful treatment of pilonidal sinus after explatnation of its causative process. Anz Journal of Surgery 62: 385-389.
  9. Lesalnieks I et al (2019) The management of pilonidal sinus. Dtsch Arztebl Int116: 12-21.
  10. Melnik B et al (2018) Acne and rosacea. In: Braun-Falco`s Dermatology, Venerology Allergology G. Plewig et al. (Hrsg) Springer Verlag S 1324
  11. Testini M et al (2001) Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique. Colorectal Dis 3: 427-430
  12. Sondenaa K et al (2002) Influence of failure of primary wound healing on subsequent recurrence of pilonidal sinus. combined prospective study and randomised controlled trial. Eur J Surg 168: 614-618
  13. Downs AM, Palmer J (2002) Laser hair removal for recurrent pilonidal sinus disease. J Cosmet Laser Ther 4: 91
  14. Matsushita S et al (2002) A case of squamous cell carcinoma arising in a pilonidal sinus. J Dermatol 29: 757-758

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 29.10.2020