Pilonidal Cyst: Causes, Symptoms and Treatment

Pilonidal Cyst Treatment

Treatment for a pilonidal cyst varies with the severity of the condition. Here is an overview of the key options:

Home Care (for early or mild cases):

• Warm compresses: Relieve pain and encourage drainage.
• Sitz baths: Soaking in warm water relieves discomfort.
• Good hygiene: Clean and dry the area.
• Hair removal: Shaving or hair removal creams to avoid recurrence (avoid during active infection).
• Topical antibiotics: Can be useful for minor infections, but not a cure.

Medical Treatment (when infected/recurrent):

Incision and Drainage (I&D) – Most frequent first-line treatment

• Performed under local anesthesia.
• Debris and pus are drained.
• Wound is left open and allowed to heal from the inside out.
• Recovery time: several weeks.
• May come back if not followed by proper hygiene/hair removal.

Antibiotics – Prescribed with I&D only when:

• There is cellulitis (circulating skin infection).
• Patient has fever or compromised immune system.
• Not effective as a single intervention.

Surgical Treatment (in case of chronic/recurrent cysts):

Excision and Healing by Secondary Intention

• Cyst and sinuses are entirely excised.
• Wound not closed, allowing it to heal naturally.
• Low recurrence, but delayed healing time.

Excision with Primary Closure

• Wound is closed and cyst is excised.
• Earlier healing, but moderate increase in recurrence.

Flap Surgery (e.g., Bascom or Limberg flap)

• Tissue is transposed to cover.
• Lower recurrence and faster healing.
• Reserved for complex or recurrent cases.

Pilonidal Sinus Symptoms

Pilonidal sinus symptoms can vary depending on whether the sinus is infected or not. Here’s a breakdown:

Common Symptoms (especially if infected or forming a cyst):

• Pain or tenderness
• Swelling or a lump
• Redness and warmth
• Pus or bloody discharge
• Fever (in severe infection)
• Multiple small holes or pits in the skin
• Recurrent infections or abscesses

Pilonidal Cyst Causes

A pilonidal cyst is most commonly due to hair, debris, and friction against the skin at the tailbone area. Following are the key causes and factors:

Primary Cause:

• Ingrown hair: The hair penetrates the skin and triggers a foreign body reaction that results in infection and cyst development.

Contributing Factors:

Friction and pressure

• Sitting for long periods or activities such as biking or driving for many miles can aggravate the region.

Poor hygiene

• Increases the likelihood of bacterial infection and hair follicle blockage.

Sweating

• Provides a warm, moist environment conducive to infection and hair buildup.

Hairy or coarse body hair

• Individuals with thick or heavy hair in the lower back region are more susceptible.

Obesity

• Places pressure on the sacral area and can cause skin folds where debris accumulates.

Tight clothing

• Increases friction and causes hair to penetrate into the skin.

Trauma or repeated irritation

• Previous trauma or recurrent stress on the tailbone region can result in cyst formation.

Pilonidal Cyst Surgery

Pilonidal cyst surgery is necessary when the cyst is recurrent, infected, or fails to heal with drainage alone. Below is a comprehensive description of the surgeries:

Types of Pilonidal Cyst Surgery

Incision and Drainage (I&D)

• Purpose: To alleviate pain and drain pus from an infected cyst.
• Procedure: Miniature incision to drain the abscess.
• Anaesthesia: Local.
• Healing time: Short (1–2 weeks), but high rate of recurrence if performed alone.
• Not a cure, typically a temporary relief.

Excision with Healing by Secondary Intention

• What's done: Whole cyst and sinus tracts excised; wound left open to heal by itself.
• Advantages: Less chance of recurrence.
• Disadvantages: Longer healing time (up to 6 weeks).
• Care: Wound must be cleaned and dressed daily.

Excision with Primary Closure

• What's done: Whole cyst is excised, and the wound is closed with stitches.
• Advantages: Quicker healing (2–3 weeks).
• Disadvantages: Slightly increased rate of recurrence.
• Care: Pressure on the area during healing should be avoided.

Flap Procedures (for chronic or complicated cases)

Examples:

• Limberg flap
• Bascom cleft lift procedure
• Karydakis flap
• Z-plasty
• Rhomboid flap
• What's done: Cyst is excised, and skin is rearranged to flatten the cleft and minimize hair/debris accumulation.
• Advantages: Extremely low recurrence rates, less wound tension, faster return to activity.
• Disadvantages: More complicated, needs experienced surgeon.

Pilonidal Sinus Treatment

Treatment of pilonidal sinus is based on stage—acute (infected), chronic, or recurrent. Below is a clear-cut treatment outline:

Non-Surgical / Conservative Treatments (For minor or initial cases)

Hygiene and Hair Removal

• Keep the site clean and dry.
• Shave or have laser hair removal done to avoid recurrence.
• Warm Compresses and Sitz Baths
• Reduce inflammation and allow natural drainage.
• Antibiotics (only if infected signs such as fever or redness spreading)
• Not a cure by itself—used as adjuvant care.

Minimally Invasive Procedures

Incision and Drainage (I&D)

• For abscesses (painful, pus-filled).
• Cut to drain pus; temporary relief.
• Wound left open to heal on its own.
• May recur without additional treatment.

Pit Picking or Bascom Procedure

• Small cuts made to remove infected pits and sinus tracts.
• Rapid recovery usually performed under local anaesthesia.
• Low pain and minimal downtime.

Surgical Options (For chronic or recurrent sinus)

Excision with Healing by Secondary Intention

• Whole sinus excised; wound left open to heal slowly.
• Extremely low recurrence, but 4–8 weeks may pass before healing.

Excision with Primary Closure

• Sinus is closed with sutures after excision.
• Heals quicker, but very small increased risk of recurrence.

Flap Procedures (for complex or recurrent cases)

• Types: Limberg flap, Karydakis flap, Z-plasty
• Skin is rearranged to flatten the region and avoid trapping hair in the future.
• Best long-term outcomes with low recurrence.
• Performed under general or spinal anaesthesia.

Pilonidal Cyst Laser Treatment

Laser pilonidal cyst treatment is a new, minimally invasive procedure, most commonly known as laser pilonidoplasty. It is gaining popularity based on less pain, quicker recovery, and less recurrence.

What Is Laser Pilonidoplasty?

• A fiber-optic laser is passed through a small incision into the sinus tract.
• The laser kills the cyst wall and closes the tract with controlled heat.
• Performed under spinal or local anaesthesia.
• No significant cutting or sutures required.

Pilonidal Cyst Removal Recovery

Healing after pilonidal cyst surgery varies according to the procedure type. Let's have a summary of recovery expectation, care, and timeline for various techniques:

Recovery Timeline by Procedure Type

Incision and Drainage (I&D)

• Healing time: 1–3 weeks
• Wound left open to drain and heal.
• Wound dressing changes necessary every day.
• Pain: Mild to moderate for several days.
• Work/school: Resume in 2–5 days.

Excision with Secondary Intention (Open Wound)

• Healing time: 4–8 weeks or more.
• Heals from the bottom up (no stitches).
• Requires frequent dressing of the wound.
• Lower rate of recurrence, longer downtime.
• Work/school: Back in 1–2 weeks, based on activity.

Excision with Primary Closure (Stitches)

• Healing: 2–4 weeks.
• Closed with stitches or staples.
• Can have drain tube for few days.
• Work/school: Back in 1–2 weeks.
• Recurrence risk mildly increased.

Laser Pilonidoplasty (Minimally Invasive)

• Healing: 3–7 days.
• Small incision, low wound care.
• Extremely minimal pain and virtually no downtime.
• Work/school: Usually within 2–3 days.

Pilonidal Cyst Infection

A pilonidal cyst infection happens when the cyst—most often near the tailbone—becomes inflamed because of embedded hair, sweat, and bacteria. Here's what you should know:

Symptoms of Infection

• Swollen, painful lump or tender swelling near the tailbone
• Redness and heat in the area
• Pus or bloody drainage (possibly smelly)
• Fever or chills (in worse infections)
• Trouble sitting or walking
• Skin opening or several small openings with drainage

Reasons for Infection

• Ingrown hair and embedded debris
• Friction due to sitting or constricting clothing
• Inadequate hygiene or perspiration
• Incomplete or delayed treatment of a previous cyst

Pilonidal Cyst Diagnosis

The diagnosis of a pilonidal cyst is normally easy and rarely needs lab tests or imaging except in the event of suspected complications. This is how it's done:

Physical Examination

• Part examined: Crease at top of buttocks (close to tailbone).

Physician looks for:

• Redness or irritability of skin
• Swelling or painful bump
• One or more small openings (sinus tracts)
• Discharge of pus or blood
• Infection signs (redness, unpleasant odor, tenderness)

Medical History

Physician might inquire:

• When did symptoms begin?
• Any drainage, fever, or pain?
• History of previous episodes or surgeries?
• Sitting position, family history, or hygiene?

Imaging (only when indicated)

Used sparingly unless:

• Deep or recurrent sinuses
• Uncertain diagnosis
• Planning for surgery
• Imaging modalities:
• Ultrasound: To identify fluid-containing cavities.
• MRI or CT scan: For complicated/recurrent cases to delineate sinus tracts.