Pilonidal sinus

A pilonidal sinus is a small hole or "tunnel" in the skin. It usually develops in the cleft of the buttocks where the buttocks separate.

Introduction

A pilonidal sinus is a small hole or "tunnel" in the skin. It usually develops in the cleft of the buttocks where the buttocks separate.

More than one hole may develop, and often these are linked by tunnels under the skin.

Most people associate the word sinus with the nose, but sinuses can occur anywhere in the body. Sinus is simply a medical term for a channel or cavity.

A pilonidal sinus will not usually cause any noticeable symptoms unless it becomes infected. This can cause a pus-filled abscess to develop. Signs that you may have an infection include pain, redness and swelling in the affected area.

See your doctor as soon as possible if you think you have a pilonidal sinus. Without treatment, any pain and infection may get worse.

Your doctor should be able to diagnose a pilonidal sinus after carrying out a visual examination of the affected area of skin. Further testing is not usually required.

Read more about the symptoms of pilonidal sinus.

Why do pilonidal sinuses happen?

The exact cause of a pilonidal sinus is unclear, although it is thought to be caused by loose hair piercing the skin. The term "pilonidal" is Latin for "nest of hairs".

Certain things can increase your chances of developing a pilonidal sinus, such as being obese, having a large amount of body hair and having a job that involves a lot of sitting or driving.

Read more about the causes of pilonidal sinus.

How are pilonidal sinuses treated?

If you have a pilonidal sinus, it is important to keep the area clean and dry. It may also help to remove any hair near the sinus. These steps can reduce the risk of infection.

Showering at the end of the day to remove hairs fallen from your head or back into the cleft between your buttocks may also help.

If a pilonidal sinus becomes infected, it should be treated as soon as possible, as it is likely to get worse.

You may initially be treated with antibiotics, but you will also need to have the pus drained out of the abscess during a minor surgical procedure called incision and drainage.

If it keeps becoming infected, surgical removal of the sinus is usually recommended. Several techniques can be used to do this, including:

  • cutting out the sinus and leaving the wound open so it can heal, and packing it daily with a dressing
  • closing the wound with a flap of skin and stitches
  • scraping out the sinuses and filling them with a special glue

It is important to carefully look after any area of skin that has been operated on, as there is a chance you will become infected again. This involves things like regularly changing dressings and keeping the area clean.

Read more about treating pilonidal sinus.

Symptoms

A pilonidal sinus is a small hole or channel in the skin that most commonly occurs at the top of the cleft between your buttocks. It may not cause any noticeable symptoms unless it becomes infected.

However, not all pilonidal sinuses occur near the buttocks. They have also been recorded in the belly button or between fingers. In many cases, there is more than one channel.

If the sinus becomes infected, an abscess will usually develop. An abscess is a painful collection of pus that causes symptoms such as:

  • pain
  • redness of the skin
  • pus draining from the sinus (the pus usually smells unpleasant)
  • blood draining from the sinus
  • a high temperature of 38ºC (100.4ºF) or above, although this is uncommon

These symptoms may develop quickly, often over a few days.

The pain caused by a pilonidal sinus can be severe and is likely to get worse without treatment. This can make it difficult to sit or lie down comfortably, which may affect your sleep. The pain may also affect your ability to work and your daily activities.

You should see your doctor as soon as possible if you suspect you have the condition. They can examine you and discuss possible treatments.

Read more about treating pilonidal sinus.

Causes

The exact cause of pilonidal sinuses is unclear. It is generally thought they are caused by loose hairs that push into the skin.

There are several theories as to how this could happen.

Hair follicles

Hair follicles are the small holes that an individual hair grows out of. It is thought that pressure and friction on a hair follicle could somehow damage it, causing a pilonidal sinus.

If a hair follicle becomes blocked, it can become enlarged and then burst. A broken hair may push into the skin, leading to an infection.

This may explain why pilonidal sinuses are common around the buttocks, as sitting and driving will cause pressure and friction on this area.

There have been reports of hairdressers developing pilonidal sinuses on their hands. This may be caused by hair becoming trapped in moist, damaged skin between a hairdresser's fingers.

Infection of the pilonidal sinus

If a broken hair pushes into the skin, the skin becomes irritated, red and swollen. Bacteria can quickly infect this skin. The cleft between the buttocks is an ideal place for bacteria to spread, as it is often moist and warm.

When the skin is infected, the immune system (the body's natural defence against infection and illness) tries to fight the bacteria, which results in a collection of pus known as an abscess.

Increased risk

Some things are known to increase your risk of pilonidal sinuses, including:

  • obesity – having a body mass index (BMI) of 30 or above
  • age – pilonidal sinuses can occur at any age, but are more common in young adults between the ages of 20 and 40
  • having an above average amount of body hair, which may be why more men are affected than women
  • having coarse and curly body hair
  • a previous injury to the affected area of skin, for example from a fall
  • having a deep cleft between your buttocks
  • having a family history of the condition – more than one-third of people have a family member with the condition
  • having a job that involves a lot of driving or sitting down for long periods

Jeep seat

During the Second World War, thousands of army jeep drivers developed pilonidal sinuses. The condition became so widespread that it was nicknamed "jeep seat", or "jeep disease".

The fact that so many men doing the same sort of job developed pilonidal sinuses suggests that environmental factors must play a role in the development of the condition. These factors could include:

  • wearing restrictive clothing, such as army uniforms
  • repetitive motion, such as bouncing around in the seat of a jeep

Treatment

Treatment may not be necessary for a pilonidal sinus if it's not infected.

It is important to keep the area as clean and dry as possible. Removing hair from the area is also advisable, usually by shaving or using hair removal creams. This should reduce the risk of an infection.

If your pilonidal sinus does become infected, surgery is likely to be recommended.

Incision and drainage

Incision and drainage involves opening the sinus up and draining away the pus. This procedure can usually be carried out at your local hospital under general anaesthetic, so you will be asleep during the operation.

It's a relatively minor operation, so you should be able to return home either the same day or the day after the procedure.

After the operation, a dressing is applied to help the wound heal. It should be arranged for your dressing to be changed daily by the practice nurse at your local doctor surgery. See the advice below for tips on how to look after your wound.

Treating recurring infection

When there is discharge of pus from the sinus without an abscess, antibiotics may be prescribed to keep the infection under control while you wait to see a surgeon. This will not cure the pilonidal sinus, however.

If the pilonidal sinus keeps becoming infected, surgery may be recommended to remove the sinus and prevent further infections. This can be done in a number of ways. In most cases, operations called wide excision or excision and primary closure are used.

Wide excision

During wide excision, the surgeon cuts out the section of skin containing the sinus. The wound is left open and packed with a dressing.

The advantage of having a wide excision is that the chances of infection returning are low. But the wound will take a long time to heal and your dressings need to be changed daily for two or three months.

Excision and primary closure

During an excision and primary closure, the surgeon cuts out the section of affected skin before closing and sealing the wound with stitches. The advantage of this technique is that the wound heals quickly. However, the chances of the infection returning are higher than with a wide excision.

There are different methods of using a flap of your own skin and tissue to fill and close the wound. Your surgeon can explain the technique they will use in more detail.

Fibrin glue

Some pilonidal sinuses can be treated by scraping away ingrown hairs and other debris from the sinus, before sealing the area with a special absorbable glue called fibrin glue. This can be done under general or local anaesthetic, depending on your preference.

The advantage of this treatment is that you do not need any dressings and there is little pain. You will probably be able to return to normal activities within a week. The risk of infection is similar to excision and primary closure. However, this procedure is relatively new and may not be available in your local area.

After surgery

You may feel some discomfort after your operation. You should be given pain relief and you may also be given painkillers to take at home. You will usually be discharged on the day of your operation.

After your operation, you will probably need time off work, although this will depend on how you are feeling and the type of work you do. Avoid strenuous work for up to two weeks.

You can start to exercise and play sport as soon as you feel able to. However, if you have stitches, you may need to avoid activities that could disrupt the stitches for two to four weeks.

Wound care

Whatever type of operation you have, it is important to keep the site of the wound clean. Your surgeon can advise about how to do this, which may include the following points:

  • Have a shower or bath at least once a day if your wound is being left open and packed with a dressing.
  • If your wound is closed with stitches, avoid having a bath. You may be advised to keep the wound completely dry for the first few days. Ask your surgeon for advice.
  • When washing the wound, do not use soap because this will irritate your skin. Use plain water and a soft cloth instead.
  • Do not use talcum powder.
  • Carefully dry the area after washing using a soft towel, but do not rub the skin. Using a hair dryer is a good way of drying the area.
  • Always remove a damp or wet dressing and replace it with a dry, clean one.
  • Wear loose-fitting cotton underwear and avoid synthetic underwear, such as nylon.
  • Eat high-fibre foods to help soften your stools and reduce any straining when you go to the toilet.

Complications

Several complications can occur as a result of surgery for a pilonidal sinus. These include:

  • recurrent pilonidal sinus (pilonidal sinus returning after treatment)
  • infection at the site of the wound during or after surgery

Contact your doctor immediately if you notice any signs of infection, such as:

  • pain
  • red, swollen skin
  • a high temperature of 38ºC (100.4ºF) or above
  • a feeling of heat at the site of the wound
  • fluid, pus or blood leaking from the site of the wound
  • an unpleasant smell coming from the site of the wound
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