Pilonidal disease: Clinical sciences

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Introduction0:00–1:09

Pilonidal disease refers to an acute or chronic infectious process within the natal cleft of the intergluteal or sacrococcygeal region.
To review some embryology. The natal cleft or sulcus forms as a result of the anchoring of the deep layers of the skin to the anal coccygeal raphe and the dorsum of the coccyx up to the tip of the sacrum.
Pilonidal disease is related to mechanical forces causing damage on the skin around the area as well as disruption and breakage of hair follicles.
And ultimately leading to the formation of natal cleft pores where broken hairs and skin debris can accumulate. This is most commonly seen in young biologically male patients.
Pilonidal disease can present acutely as an infection such as folliculitis or cellulitis or the infectious process can further develop into an abscess.
On the other hand, in chronic pilonidal disease, there are pilonidal cysts sinuses or tracts that contain inspissated debris such as hair and skin debris.
That's right. We're talking about a crack attack when a patient presents with a chief concern, suggesting pilonidal disease.

History and Physical - Acute Pilonidal Disease1:09–2:18

Your first step is to obtain a focused history and physical examination which will help determine if they have an acute or chronic disease.
All right. Some patients might report mild to moderate pain at the location of the intergluteal or sacro coccygeal region.
The pain is usually associated with movement that causes the skin area to stretch. They might also report intermittent swelling along with purulent mucoid or bloody drainage from the location as well as a fever, which means that an abscess might have formed.
Now, on a physical exam, you'll typically find primary or midline natal cleft pores that may be acutely infected with signs of cellulitis like erythema and swelling or folliculitis such as papules or pustules on an erythematous base.
If your patient presents with this clinical picture, you can diagnose your patient with acute pilonidal disease. Now that you have made the diagnosis, the next step is to assess if there is an associated abscess.

Abscess2:18–3:19

If there is one youll see a painful erythematous lump and youll feel fluctuant and might be able to express drainage. If these findings are present, you can diagnose your patient with a pilonidal infection with an abscess.
The next step will be to consult the surgical team for incision, drainage and curettage. Ok.
Even though the abscess is drained, you're still not done. In some cases, the abscess might remain after treatment or it might reaccumulate in 48 to 72 hours.
So, if you see findings consistent with reaccumulation, a remaining fluid collection or a loculated abscess, it means that your patient has a refractory abscess or infection.
If this is the case, consider repeat incision and drainage or adding an antibiotic to treatment. Ok.
Let's go back to the diagnosis of acute pilonidal disease. If the patient's history and physical exam show a painless lump with no signs of an abscess like fluctuant or drainage, you can diagnose pilonidal infection.

No Abscess3:19–4:21

Once the diagnosis is made, start the treatment with oral antibiotics. Ok.
Once you have started antibiotics, you should wait for 48 to 72 hours to assess the response to treatment. If the response is adequate, which means that the signs of cellulitis or folliculitis are improving, you can complete the course of antibiotics.
However, if the response to treatment is inadequate, meaning that there is little or no improvement, you need to switch up their treatment.
This means that you should consider broadening or switching antibiotics. Here is a clinical pearl to keep in mind.
Once the treatment for acute disease is complete, you should think about providing definitive management of your patients.
Pilonidal disease, which might include surgical excision or local phenol injection. All right.
Now that we've dealt with acute pilonidal disease, let's go all the way back to history and physical exam and talk about a chronic presentation as before the patient might report mild to moderate pain in the intergluteal region.

Chronic Pilonidal Disease4:21–6:25

However, what will indicate chronic infection is persistent and recurrent drainage from one or more sinus tracts on a physical exam.
You may see these sinus tracts or openings, draining purulent mucoid or bloody fluid as well as a hair protruding from the opening.
These tracks are typically painless in nature. You may also notice primary or midline as well as secondary or lateral natal cleft pores.
Typically chronic pilonidal disease is a result of a previously drained abscess that is filled with granulation, tissue, hair and skin debris.
So be sure to ask about previous abscesses and their treatment. If you see all these findings together, you can diagnose your patient with chronic pilonidal disease.
All right, let's move on to management. Once you have made the diagnosis, you should consult surgery for excision or local phenol injection, which are used to destroy all sinus tracts and skin pits that are present.
Surgical excision does this by unroofing and debriding the tracts. Keep in mind that the walls of the cyst must be removed to prevent recurrence.
This can end up requiring a large excision of tissue and may need reconstructive techniques. On the other hand, for phenol injection tracts remain intact from the outside.
First, tracts are surgically cleaned of any hair and debris. Then phenol is injected into the tract.
Phenol acts as keratolytic, which means that it destroys anything containing keratin like skin cells and hair, creating a scar tissue that fills in the sinus tract and cavity.
Once the treatment is complete, tell the patient to keep the area clean. Also consider methods of natal cleft hair control such as epilation because they may reduce recurrence.

Review6:25–7:19

All right. As a quick recap, pilonidal disease may have acute or chronic presentation.
Patients who present with acute pilonidal disease typically have folliculitis or cellulitis. In addition to this, an abscess may also be present which requires prompt incision and drainage along with curettage.
If this doesn't improve, you must consider a refractory abscess or infection and proceed with repeat incision and drainage or adding an antibiotic.
On the other hand, if there is no abscess, treat them with antibiotics. If there's adequate response, you can complete the course of antibiotics and no additional treatment is needed.
If there's inadequate response, you may need to broaden or switch antibiotics. In addition to assessing for abscess or spreading infection.
When it comes to chronic disease, its treated with surgical excision or a local phenol injection.