What is pilonidal disease?
Pilonidal disease is a skin condition commonly referred to as a hair cyst. Patients can present with a variety of symptoms including pain, swelling, redness, drainage of pus and/or blood from a skin opening [Figure 1]. Symptoms can be present from days to years in some patients. Occasionally patients can present with a painful abscess that requires immediate incision and drainage. The condition predominantly affects young people from teenage years into adulthood. The cyst typically occurs between the cheeks of the buttocks around the tailbone. The main risk factor is excessive hair. The treatment of pilonidal disease can range from incision and drainage of an abscess, removing the pits and sinus openings [Figure 2], laser treatment of the tracts, unroofing and marsupialization of the wound, to complex resection of the area with flap closure (moving healthy surrounding tissue to cover the wound). Dr. Maher Abbas employs simple and minimally invasive techniques for most patients.
Figure 1- Pilonidal cyst opening
Figure 2 – Sinus openings in the midline with a cyst on the right
Postoperative Wound Care Instructions
The surgical procedure that Dr. Maher Abbas performs on you is a critical step to help you with your condition. However equally as important is wound care. It is imperative that you follow all instructions and that you take daily care of your wound. Because of the location of pilonidal disease, you often will need the assistance of another person to care for your wound. Dr. Maher Abbas encourages you to bring to the hospital and clinic, the person who will be helping you so that he/she is taught proper wound care. Instructions will vary depending on the type of intervention you have. You can shower as early as 24 to 48 hours but no scrubbing or soaking of the wound. Pat dry the wound rather than wiping. When you go to the toilet to defecate, do not wipe your anus towards the wound. Wash the anus and pat dry. Hair removal as described below is a critical part of your wound management.
Incision and drainage of an abscess
If you had an abscess drained, a small packing will be left in the wound overnight to be removed the following morning. There is no need to repack the wound. Wash and irrigate the wound with liquid soap and water twice a day. Pat dry the wound and apply antibiotic ointment such as Fucidin or Bacitracin twice a day. Cover with a dry gauze. Continue this care until the skin closes. Keep the area free of hair. Healing typically occurs within 2 weeks.
Laser obliteration and pit removal
With laser obliteration the pit openings are removed and the tracts are debrided before treating with a laser beam. Gently wash the area with soap and water. Pat dry. Apply antibiotic ointment to any small opening and cover with a dry gauze. Continue this care until the skin is dry and closed. Keep the area hair free. The sinus openings usually heal within 2-3 weeks.
Unroofing and marsupialization
In this technique the sinus tracts are opened and debrided without removing any tissue. The edges of the skin are sutured to the middle of the wound which is kept open. Remove the surgical dressing and wash the wound the following day. Pat dry. Fold a thin dry gauze and stuff the edge into the deep portion of the wound as instructed by Dr. Maher Abbas. Change 2 to 3 times a day. Ensure that the edge of the gauze is in contact with the deep portion of the wound to ensure good healing. Cover with a dry gauze. Keep wound free of any hair. Depending on the size of the wound complete healing takes between 3 and 8 weeks.
Excision and flap closure of the wound
For patients who presents with persistent or recurrent complex disease after previous interventions, Dr. Maher Abbas will remove the infected and scarred area and close the wound with an adjacent flap (rotate healthy tissue to cover the wound). A surgical drain is often placed to aid with the healing (see section on Surgical Drain Care). The drain is usually needed for 1 to 2 weeks. Remove the dressing 48 hours after surgery. Gently wash the wound with liquid soap and water. Cover suture lines with antibiotic ointment and a dry gauze. Wound healing typically occurs within 2 to 4 weeks.
Hair removal
A major risk factor for non-healing or recurrence of pilonidal disease is hair infiltration of the wound. It is imperative that you are very diligent with hair removal from the wound and surrounding skin. Even after closure of the skin, the wound scar is soft and hair can poke through the skin and cause the disease to come back. Dr. Maher Abbas recommends hair removal during your recovery period and for at least 6 months after surgery until the scar of the wound is mature and complete.
In the early recovery period, Dr. Maher Abbas recommends hair removal using an eyebrow tweezer and creams such as Nair, Veet, Nad. Several other organic creams are available. Use the tweezer to pull any hair out of the wound. Apply the cream to the adjacent skin every 1 to 2 weeks. You can use a cotton Q-tip for accurate application. Follow the instructions in the package insert. Leave for a few minutes but do not exceed 10 minutes. Do not rub the cream. Do not put the cream inside the wound or apply to the anal area. Use a damp washcloth to wipe off the cream. Rinse with warm water in the shower to remove any excess cream and wash the wound. Pat dry.
Activity
It is best to rest the first week following your surgery to allow the area to heal. Walking and slow climbing of the stairs are permitted once you are home. However, avoid strenuous activity or vigorous exercise such as bicycle riding, jogging, weight lifting, tennis, or aerobic exercise for 2 to 4 weeks (or longer if instructed by Dr. Maher Abbas). Avoid excessive friction of the buttocks area and keep the area dry.
Diet
Have a regular diet with high fiber content and drink plenty of liquids (see High Fiber Food). Avoid constipation and straining.
Medications
You can resume your home medications unless instructed otherwise. If mild ache or discomfort, take 1 to 2 tablets of Tylenol [paracetamol 500 mg] every 6 hours as needed [can take up to 6 tablets per day]. If you are prescribed a non-steroidal anti-inflammatory medication (NSAID) such as Voltaren, Advil, Aleve, Ibuprofen, always take it with food. Do not exceed the prescribed dose or frequency. Sometimes you will be prescribed an anti-acid medication to protect your stomach (such as Gaviscon, Zantac, Pepcid, Tagamet, Nexium, Prilosec, Pantazol). If other pain medications or antibiotics are prescribed, take them as directed. Drink plenty of water with medications.
Signs to watch for
For an open wound, clear secretions and light streaks of blood are to be expected until the wound is closed. For a closed wound there should be minimal amount of secretions that should subside within the first 2 weeks. Pain and discomfort is anticipated for 1 to 2 weeks but should diminish. If any of the following symptoms occurs, inform Dr. Maher Abbas’ office:
- Bleeding from the wound
- Fever (Temperature >38 ° Celsius, >100.4 ° Fahrenheit)
- Redness that spreads beyond the edges of the wound
- Thick milky drainage from the wound
- Separation of the sutures if you have a closed wound
Follow-up appointment
You will be scheduled for weekly office follow-up visits until the wound is healed. The purpose of the visits is to inspect the wound, perform any debridement or hair removal if necessary. In some cases, you will be seen more frequently. It is imperative that you show up to all your scheduled appointment to ensure proper wound care in order to maximize healing. If you have sutures in the wound they are typically removed between 2 and 3 weeks. If you have any concerns or new findings, you can return to the office at any time.
Any questions? Contact Dr. Maher A. Abbas’ office nurse here.