Pilonidal Sinus And Abscess

Topic Name Introduction Clinical Features Diagnosis Management Complications

Pilonidal Sinus and Abscess

Definition

A pilonidal sinus is a chronic inflammatory condition characterized by a sinus tract or cavity containing hair, typically occurring in the sacrococcygeal region. The term "pilonidal" derives from Latin, meaning "nest of hair."

Epidemiology

• Peak incidence: Adolescence and early adulthood (15-24 years)
• Male predominance (male to female ratio 3:1)
• More common in individuals with:
  • Thick, coarse body hair
  • Deep natal cleft
  • Prolonged sitting occupations
  • Family history

Pathophysiology

The condition develops through several mechanisms:

1. Hair Insertion:
   • Loose hair penetrates the skin in the natal cleft
   • Mechanical forces and movement drive hair deeper
   • Local trauma and friction contribute to formation
2. Foreign Body Response:
   • Hair acts as foreign body
   • Triggers inflammatory response
   • Forms epithelialized tract
3. Secondary Infection:
   • Bacterial colonization occurs
   • Leads to abscess formation
   • Can cause acute exacerbations

Presentation

• Asymptomatic Phase:
  • Small dimple or pit in natal cleft
  • May have visible hair protruding
  • No pain or discharge initially
• Acute Phase:
  • Pain and tenderness
  • Swelling and redness
  • Abscess formation
  • Purulent discharge
  • Difficulty sitting or walking
• Chronic Phase:
  • Persistent drainage
  • Multiple sinus openings
  • Chronic inflammation
  • Scarring and tissue induration

Physical Examination Findings

• Primary midline pit(s) in natal cleft
• Secondary lateral openings may be present
• Local tenderness and inflammation
• Purulent or serosanguineous discharge
• Surrounding erythema and induration

Diagnostic Approach

1. Clinical Assessment:
   • Detailed history
   • Physical examination
   • Assessment of risk factors
2. Imaging (if needed):
   • MRI: For complex or recurrent cases
   • Ultrasound: To assess abscess extent
   • Sinogram: To map sinus tracts

Differential Diagnosis

• Hidradenitis suppurativa
• Perianal fistula
• Furuncles
• Sacral osteomyelitis
• Dermal cyst
• Anal fissure

Treatment Options

1. Conservative Management

• Regular hair removal
• Maintaining good hygiene
• Weight reduction if applicable
• Avoiding prolonged sitting

2. Medical Management

• Acute Abscess:
  • Incision and drainage
  • Antibiotics if cellulitis present
  • Pain management
• Chronic Disease:
  • Local wound care
  • Regular cleaning and dressing
  • Topical antimicrobials as needed

3. Surgical Management

• Procedures:
  • Wide excision
  • Karydakis flap
  • Bascom procedure
  • Limberg flap
• Minimally Invasive Options:
  • Pit picking
  • Endoscopic treatment
  • Sinusectomy

Potential Complications

• Recurrence (20-30% cases)
• Chronic pain
• Wound healing problems
• Scarring
• Psychological impact
• Rare: Squamous cell carcinoma

Prevention Strategies

• Regular hair removal
• Maintaining good hygiene
• Weight management
• Avoiding prolonged sitting
• Early treatment of symptoms

Prognosis

• Generally good with appropriate treatment
• Recurrence rates vary by procedure
• Better outcomes with early intervention
• Lifestyle modifications crucial

Disclaimer

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