Pilonidal sinus, also known as PNS, is something I had to battle with personally for years and is known as the ‘ugly disease’ among professionals in the UK.
There are so many different treatment options when it comes to surgery; this coupled with wildly conflicting and often misleading information around post-operation aftercare meant I suffered greatly during my 18-month battle following my first surgery of five.
This guide will provide you with all of the key information you need to know about pilonidal sinus disease in general, approved by Mr Emin Carapeti – one of the best around when it comes to PNS.
What is Pilonidal Sinus?
Pilonidal sinus, by definition, is an inflammatory condition that affects the inter-gluteal region between the buttocks (natal cleft) over the sacrum (base of the spine) and the coccyx (commonly referred to as the tailbone).
Pilonidal sinus disease is frequently incorrectly described as a congenital ‘cyst’; however, it is an acquired condition, most commonly occurring between the ages of 16-25.
Causes of Pilonidal Sinus
You will find conflicting information online about what causes pilonidal sinus disease.
However, the medical root cause is when there is an injury to the hair follicles in the deep natal cleft.
Then, the resulting folliculitis leads to swelling and a localised abscess which ruptures, but fails to heal, leaving small holes or ‘pits’ behind.
Once this occurs, several hair follicles are being driven into the pits, predominantly by the forces of the moving buttocks in day-to-day life.
The result of this is micro tunnels, also known as ‘sinuses’, developing under the skin, which are closed off at one end.
Symptoms of Pilonidal Sinus
It is important to note that a lot of people can have pilonidal sinus disease, but also be asymptomatic.
This happened to me at the start of my pilonidal sinus journey and noticeable symptoms only started to develop later down the line.
Most pilonidal sinus cases occur chronically, with one or more holes or pits on the midline (natal cleft).
From the pits, you will likely experience some notable symptoms at some point, including:
- Discharge openings (also known as fistulas)
- Swelling
- Pain to touch (soreness)
- Smell (infection)
Risk Factors of Pilonidal Sinus
The research on what increases the risk of pilonidal sinus disease is outdated and unproven.
However, there have been several risk factors identified that could be seen to increase the chance of pilonidal sinus disease occurring – these are:
- Gender
- Age
- Ethnicity
- Hair
- Obesity
- Lifestyle/Occupation
- Hygiene
- Irritation
- Deep Natal Cleft
- Hirsutism
Gender
When it comes to gender, PNS disease is more likely to occur if you are male rather than female.
This is due to the fact the male species generates more hair in the buttocks region. One article suggests that pilonidal sinus disease is 2-4 times more likely to occur in men than women.
Age
PNS disease is generally considered to develop after puberty.
According to a clinical review by Lilian Bradley, it is thought to peak for females at 19 years old and males at 22 years old.
Hormonal influence is said to be an important factor, which makes PNS disease rarely present in people over the age of 40.
Ethnicity
Due to different hair growth patterns and characteristics, PNS disease is more likely to occur in white people.
Hair
Those with coarse hair – a hair type that is thicker and wider in diameter than average – are also considered to be at a higher risk of developing pilonidal sinus disease.
Obesity
Those with obesity are also considered to be at a higher risk of developing pilonidal sinus disease.
This concept is derived from the increased friction and sweating that will occur in the buttocks region.
Lifestyle/Occupation
Those with a lifestyle or occupation that requires prolonged sitting are also considered to correlate with an increased risk of PNS disease.
Once again, this is due to the increased pressure and friction on the buttocks. A study from 2010 by Ali Harlak suggests that ‘prolonged’ sitting is more than six hours per day.
Hygiene
Poor hygiene is another factor believed to increase the risk of PNS disease; however, there is a lack of evidence to prove this.
Most doctors believe it contributes, but studies and trials lack data due to individuals not wanting to admit to poor personal hygiene.
Irritation
Trauma or irritation are considered to be risk factors for PNS disease.
The belief is that activities such as cycling or prolonged sitting cause more irritation and trauma to the buttocks region, which could increase the risk of pilonidal sinus forming.
Also, ingrown hairs and friction are more likely to contribute to infections as they cause inflammation, leading to bacterial invasion.
Deep Natal Cleft
Having a deep natal cleft is also said to be a risk factor for PNS disease.
If you have a deep natal cleft, this allows an accumulation of debris and hair follicles to gather, which increases friction and promotes hair regression.
It also means there is an increased moisture level, making it more difficult to keep clean and bacteria is likely to build up.
Hirsutism
Hirsutism, by definition, is the growth of excessive male-pattern hair in women after puberty.
This condition makes it more likely for women to develop PNS disease, linking back to the ‘hair’ risk factor previously mentioned.
Note: To reiterate, these risk factors are not direct, proven causes of pilonidal sinus disease. Most studies and research are outdated and lack concrete evidence or correlation.
When Should You Go To See Your GP?
When I first had pilonidal sinus, I was completely oblivious to what it was and when I needed to go to see a doctor.
According to the NHS, you should go to your GP when you notice one or more of the following:
- You notice a small lump at the top of your bottom
- The lump is painful
- The lump is bleeding
- The lump is leaking pus/smells bad
I would certainly agree with this advice. I first went to see my GP when I noticed yellow pus and the smell was not good. Make sure to get it checked out as soon as you can.
Treating Pilonidal Sinus
Surgery is the only way to treat the cause of the abscess and remove all of the infected tissue.
The type of surgery you have to remove the pilonidal sinus is vital. There are multiple options to choose from; always make sure you see an expert in pilonidal sinus disease to evaluate and decide on the best option for you, otherwise, it could lead to further complications.
There are two main options when it comes to removing the pilonidal sinus:
Open Wound Procedure
This surgery type will involve a wide excision of the skin area surrounding the pilonidal sinus, with the sinus itself also removed.
The wound is left open to heal naturally from the inside and gradually closes together, should there be no complications.
You will require general anaesthetic for this procedure – the usual recovery time (depending on the specific surgery method used) is 6-12 weeks.
Closed Wound Procedure
This surgery type is when the sinus is removed and the skin is stitched together straight away.
You will either have dissolvable stitches that disappear naturally, or stitches that are removed anywhere from 7-14 days post-surgery.
I must reiterate that you should always speak to an expert in pilonidal sinus before having your surgery. I am someone who went through five different surgeries in 18 months, all because the wrong surgery was conducted at the start.
I recommend Dr Carapeti, a pilonidal sinus expert I went to see after my fourth surgery as I was completely lost. His expertise with pilonidal sinus is among the top in the UK and you should book a consultation to see him privately to assess your sinus and decide on the best surgery option for you.
There are multiple approaches to treating pilonidal sinus with over 100 different surgery options (all falling under the open and closed wound approaches). This is why you must see an expert before going ahead to increase the chance of success.
Aftercare for Pilonidal Sinus
I have created PNS Hub as the go-to resource for those seeking the correct advice for pilonidal sinus aftercare.
Conflicting information is abundant online, so I have put together this website to answer all of the questions you have and to help you through your healing process.
Pilonidal Sinus vs Pilonidal Cyst – Key Difference
Many people often think that pilonidal sinus and pilonidal cyst are synonyms, but there is a clear difference between the two.
As mentioned earlier, pilonidal sinus is an inflammatory condition that affects the inter-gluteal region between the buttocks (natal cleft) over the sacrum (base of the spine) and the coccyx (commonly referred to as the tailbone). Namely, there are one or more pits, forming a sinus that extends from the skin openings down into the subcutaneous tissue.
A pilonidal cyst, however, presents as an enlarging lump under the skin. There are no associated pits or sinus – the cyst is a contained lump without communication to the skin. Cysts can become infected and develop into an abscess, which requires surgical drainage and subsequent elective excision surgery to remove the cyst.
Pilonidal Sinus FAQs
Here are some common FAQs about pilonidal sinus disease:
Can Pilonidal Sinus Heal On Its Own?
You can use antibiotics to treat the infection of a pilonidal sinus, but surgery is always required to fully remove the sinus.
What Is The Recovery Time After Pilonidal Sinus Surgery?
If you choose an open wound procedure, it normally takes between 6-12 weeks to heal fully and close over. You want the healing process to be natural and for healthy tissue to form from the base of the wound to the top before it closes over.
For closed wounds, the recovery time is shorter, but the risk of infection and complications are much higher.
Can Pilonidal Sinus Recur After Treatment?
Yes, pilonidal sinus can come back after surgery. However, there are steps that can be taken to reduce the risk, with one of those key steps being the type of surgery used. Make sure to speak to a pilonidal sinus specialist for this.
What Is The Best Cream To Use For Aftercare?
Personally, I used Ortem™. This is a 10% metronidazole topical cream/ointment applied to open wounds during recovery.