Pilonidalsine L05.9

Acute or chronic inflammation in the subcutaneous fatty tissue, starting from the midline of the sacral region (pilus = hair; nidus = nest). A distinction is made between asymptomatic, acute abscessing and chronic forms. In principle, pilonidal sinuses can also occur in other regions of the body, for example umbilically and interdigitally in hairdressers as trichogenic foreign body granulomas.

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

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.

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.

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.

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

In the acute abscessing form, incision is the method of choice. The optimal incision location on the apex of the abscess cavity can be determined by palpation ("doughy dent") and sonography. Intradermal local anesthesia is preferable to icing in terms of analgesia and CFC avoidance. Dermatologic biopsy punches with a diameter of 6 mm are suitable for performing the incision. The resulting circular de-roofing generally allows tamponade-free follow-up treatment.

Radical excision should not be performed at this stage due to the high recurrence rate. Once the inflammation has subsided, complete excision of the focus (en bloc excision) with subsequent secondary healing is considered standard. Routine excision down to the sacral fascia should be avoided at all costs, as it often results in treatment-resistant pain despite recurrence-free healing of the wound.

Primary openings to the side of the midline (off-midline pits), side passages and branching are atypical for pilonidal fistula and suggest acne inversa with a correspondingly less favorable prognosis. Experience has shown that the granulation and epithelialization phase lasts at least 8 weeks, but can also last up to a year depending on the size.

Surgical repair during the inflammation-free interval, if necessary after prior fistula visualization.Generous excision of the pilonidal sinus and all fistulas up to the sacrococcygeal fascia. Subsequent secondary healing of the wound.

In order to ensure granulation from the depths, the use of a special drainage procedure, e.g. Cavi-Care, has proved successful. The deep wound is filled with the two-component plastic and the resulting plug is fixed with a self-adhesive film. This tamponade must be cleaned daily and reinserted into the cavity. After approximately 8 days, the tamponade must be poured again as the wound cavity rapidly shrinks.

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

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

That is a contradiction! What is the current "state of the art"?

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).

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