From Clinic to Recovery · First Edition
Chapter 08 — Pilonidal Disease
Dr. Tamer Rushdy Elalfy · 16 min read
In this chapter
Pilonidal disease mainly affects young adults, often students, soldiers, drivers, and office workers who sit for long periods, and it is particularly common in hot climates. For these patients the important questions are practical: how long they will be off school or work, how long a wound will take to heal, whether they will be able to sit, pray, and drive, and whether the disease will come back. Treatment choices range from small procedures that allow return to normal life within days to larger operations with longer recovery, and recurrence depends strongly on the technique. Good counseling helps each patient choose the option that fits both the disease and their life.
Learning objectives After reading this chapter you should be able to:
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Table 8.1. Pilonidal disease at a glance.
| At a glance | |
|---|---|
| Who it affects | Mostly young adults, more often men, with hair in the natal cleft and long periods of sitting |
| Forms of disease | Asymptomatic pits, an acute abscess, or chronic discharging disease |
| Main treatments | Abscess drainage; minimally invasive procedures; excision with off-midline closure; excision left open |
| Time off study or work | Days after minimally invasive treatment; about 2 weeks after a flap; longer with large open wounds |
| Risks every patient should hear | Wound infection or breakdown, slow healing, and recurrence |
| The key counseling message | “The right treatment depends on how much disease you have and how quickly you need to get back to normal life. Closing the wound in the midline should be avoided.” |
STEP 1 Explaining the disease and the treatment
8.1 Three forms of the disease
Guidelines distinguish three presentations [1, 2]. Pits found by chance without symptoms do not need treatment. An acute abscess needs prompt drainage, and the incision is best placed to one side of the midline [3]; many patients need no further surgery, and a definitive procedure is offered if symptoms return. Chronic disease, with recurring discharge or pain, is treated with a definitive procedure chosen according to its extent: minimally invasive techniques for simple disease, and excision for extensive or recurrent disease [2]. Figure 8.1 summarizes the approach.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 8.1. Matching the treatment to the form of pilonidal disease.
8.2 The counseling script
Script: explaining pilonidal disease What it is. “In the groove between the buttocks, loose hairs can be pushed into the skin, especially with sitting and sweating. They make small holes, called pits, and a tunnel under the skin that can become infected. It is not a cyst you were born with, and it is not infectious to other people.” Why it comes back. “The groove is deep, warm, and moist, and hair keeps collecting there. Treatments that flatten the groove or keep the wound away from the middle help to stop it coming back.” The choices. “For a few small pits, we can clean out the tunnels through tiny cuts. You go home the same day and are back to normal within days, but it may come back more often. For larger disease, we remove the tunnels and close the skin to one side of the middle, which flattens the groove. That takes about two weeks of recovery and rarely comes back. Leaving the wound open to heal is another option, but it needs dressings for weeks.” Checking. “What matters most to you: the quickest return to study or work, or the lowest chance of it coming back?” |
8.3 Choosing the operation
Recurrence after pilonidal surgery depends strongly on the technique and on how long patients are followed. In a large meta-analysis, excision with closure in the midline had a recurrence of about 17 in 100 at 5 years, compared with about 2 in 100 after the Karydakis or Bascom cleft-lift operations, which close the wound to one side of the midline; recurrence after midline closure continued to rise over 20 years [4]. Midline closure should therefore be avoided [1]. Minimally invasive procedures cause less pain and allow a quicker return to work, and are suitable for simple disease, accepting a higher chance of recurrence [1, 2]. Table 8.2 compares the options for patients.
Table 8.2. Treatment options for chronic pilonidal disease, for use with patients.
| Option | What it involves | Recovery | Recurrence |
|---|---|---|---|
| Minimally invasive (pit picking, endoscopic, or laser) | Pits removed through tiny cuts; tunnels cleaned | Back to study or work within days; small wounds heal in 3 to 4 weeks | Higher than after flaps [unit data] |
| Excision with off-midline closure (Karydakis, cleft lift, rhomboid flap) | Diseased tissue removed; skin closed to one side, flattening the cleft | About 2 weeks off; may have a drain for a few days | Low: about 2 in 100 at 5 years after Karydakis or Bascom [4] |
| Excision left open | Diseased tissue removed; wound heals from the base | Daily dressings; healing often takes 6 to 12 weeks or more | [unit data] |
| Excision with midline closure | Wound closed in the midline | Wound breakdown is common | High: about 17 in 100 at 5 years [4]; not recommended |
Hair removal: what to tell patients Guidelines disagree about hair removal. Some recommend epilation for patients with dense hair, while the 2024 European guideline found that hair removal before and after surgery does not clearly change recurrence [2]. Laser hair removal may help some patients, but the evidence is limited. Explain this honestly, and do not make hair removal a condition of treatment. Keeping the area clean and dry, and avoiding long periods of sitting, are reasonable advice for everyone. |
STEP 2 Preparation, medicines, and recovery
8.4 Before the operation
- Timing. Ask about examinations, military service, travel, and work. Many patients choose a minimally invasive procedure or a date that allows the recovery they need.
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Risk factors. Stopping smoking and losing excess weight reduce wound problems; these can be addressed before a planned procedure [2].
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Infection. Antibiotics are not a substitute for drainage of an abscess. An acute abscess is drained first, and definitive surgery is planned once the inflammation has settled.
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Medicines and fasting. Use the standard plans in Chapters 2, 18, 22, and 23. Most procedures are day cases.
8.5 Wound care after the operation
Wound care differs with the type of operation, and patients need clear, written instructions for their own wound. After minimally invasive procedures, the small wounds are washed in the shower and covered with a light dressing. After off-midline closure, the wound is kept dry for the first days, a drain may be removed in clinic, and prolonged sitting directly on the wound is avoided until it is comfortable. An open wound is showered daily and dressed or packed by the patient, a family member, or a nurse, often for several weeks; patients should know who will help and how to obtain dressings. Keeping hair away from a healing wound is often advised.
8.6 Recovery
Table 8.3 and Figure 8.2 give typical times. Patients should be told that open wounds vary greatly in healing time with their size.
Table 8.3. Typical recovery after pilonidal surgery.
| Activity | Minimally invasive | Off-midline flap | Open wound |
|---|---|---|---|
| Showering | The next day | After 1 to 2 days | The next day, daily |
| Sitting comfortably | Within a few days | About 2 weeks; use a cushion and avoid long sitting | Within about 1 week, with a cushion |
| Driving | Within a few days | About 2 weeks | When sitting is comfortable |
| School or office work | Within a few days | About 2 weeks | Often 1 to 2 weeks, with dressings continuing |
| Sport and gym | About 2 weeks | About 4 weeks | About 4 weeks |
| Swimming | When healed | When healed, about 3 weeks | When fully healed |
| Prayer | Unchanged; a cushion helps | Pray seated on a chair if sitting on the floor stretches the wound | Pray seated if needed; protect the dressing |
| Ramadan fasting | Unchanged | When eating normally | Unchanged; keep up fluids for healing |
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 8.2. Recovery after minimally invasive treatment, off-midline flap, and open healing, for use with patients.
STEP 3 Questions patients ask
“Why did I get this?”
Loose hairs collect in the groove between the buttocks and are pushed into the skin, especially with sitting, sweating, and friction. It is common in young adults and is not caused by poor hygiene.
“Is it contagious?”
No. You cannot catch it from someone or give it to anyone.
“The pits do not bother me. Do I need an operation?”
No. Pits without symptoms do not need treatment [1]. Come back if you notice pain, swelling, or discharge.
“Can antibiotics cure it?”
Antibiotics can calm surrounding infection, but they cannot remove the hair and tunnels. An abscess needs to be drained.
“Will it come back?”
It can. The chance depends on the operation: low after a flap that moves the scar away from the middle, about 2 in 100 at 5 years; higher after smaller procedures; and highest after a midline closure, which we avoid [4].
“Why leave the wound open?”
An open wound heals from the bottom up and avoids tension on stitches. It takes weeks of dressings, so we discuss whether it suits your life before choosing it.
“Do I need to shave or have laser hair removal for life?”
Experts disagree. Hair removal may help some people, but it is not proven to stop the disease coming back [2]. Keeping the area clean and dry is helpful for everyone.
“When can I sit, study, or go back to work?”
Within days after a small procedure, about 2 weeks after a flap, and when sitting is comfortable with an open wound. We will plan around your examinations or work.
“Can I pray normally?”
You can pray from the first day. If sitting on the floor stretches or hurts the wound, pray seated on a chair until it is comfortable.
“Can it become cancer?”
This is extremely rare and happens only in disease left untreated for many years.
STEP 4 Risks, warning signs, and consent
8.7 Material risks
Table 8.4 groups the risks into the bands of Section 1.5. Replace figures marked “unit data” with your own audit figures.
Table 8.4. Material risks of pilonidal surgery. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Pain, discharge, and wound care for weeks | Most patients; longest with open wounds | “You will need wound care for some weeks, longest if the wound is left open.” |
| Common | Recurrence after minimally invasive treatment | [unit data] | “Small procedures come back more often, but can be repeated.” |
| Less common | Wound infection or breakdown after closure | [unit data] | “Sometimes part of the wound opens and then heals with dressings.” |
| Less common | Fluid collection under a flap | [unit data] | “Fluid can collect under the skin and may need draining in clinic.” |
| Less common | Recurrence after off-midline closure | About 2 in 100 at 5 years after Karydakis or Bascom [4] | “About 2 in 100 people have it come back within 5 years.” |
| Rare but serious | A wound that will not heal; persistent pain; numbness or an unsatisfactory scar | [unit data] | “Rarely, a wound takes months to heal or needs another operation.” |
8.8 Consent checklist
Before the patient signs ☐ Form of disease explained: asymptomatic, acute abscess, or chronic. ☐ Options discussed, including no treatment for asymptomatic pits and the trade-off between recovery time and recurrence. ☐ The planned technique named, including whether the wound will be closed off the midline or left open. ☐ Risks from Table 8.4, with unit figures where available. ☐ Wound-care plan agreed: who will do dressings, how to obtain supplies, and how long it may take. ☐ Timing agreed around study, examinations, military service, work, and travel. ☐ Who will perform the operation, including trainee involvement under supervision. ☐ Teach-back done, and the patient guide given in the patient’s language. |
8.9 Warning signs
Table 8.5. Green, amber, and red warning signs after pilonidal surgery.
| Level | Signs after pilonidal surgery | What to do |
|---|---|---|
| Green | Soreness when sitting that improves each week Small amounts of clear or slightly blood-stained discharge Itching as the wound heals | Expected. Follow the wound-care instructions. |
| Amber | Increasing redness, warmth, swelling, or pain around the wound Thick or smelly discharge Temperature of 38 °C or more Part of a closed wound opening | Call the clinic or contact number the same day. |
| Red | Fever with shivering and spreading redness Heavy bleeding from the wound Feeling very unwell | Go to the emergency department now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the treatment the patient had, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Treatment for Pilonidal Disease For you and your family. Keep it until your wound has healed. |
What is pilonidal disease?
Loose hairs collect in the groove between the buttocks. Sitting and sweating push them into the skin. They make small holes, called pits, and a tunnel under the skin that can get infected. It is common in young adults. It is not caused by being unclean, and you cannot pass it to anyone.
The treatment you had
☐ Drainage of an abscess
☐ Small procedure to clean out the pits (pit picking, endoscopic, or laser)
☐ Operation with the wound closed to one side (flap)
☐ Operation with the wound left open to heal
1. Pain and pain medicines
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The area will be sore, especially when sitting. This gets better each week.
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Take your pain medicines regularly at first, as we told you.
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Use a soft cushion when sitting.
2. Wound care
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Small procedure or drainage: shower daily and cover with a light dressing.
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Closed wound (flap): keep it dry for the first days, as we told you. If you have a drain, we will remove it in clinic. Avoid sitting directly on the wound for long.
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Open wound: shower once or twice a day and let the water run over the wound. Then pack or dress it as we showed you.
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Keep hair away from the wound while it heals.
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Who will do my dressings: ______________________
3. Eating and drinking
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Eat and drink normally. Protein, fruit, and vegetables help healing.
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Avoid constipation, because straining is uncomfortable.
4. Rest, washing, and clothes
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Walk around from the first day.
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Wear loose cotton underwear and clothes that do not rub.
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Do not sit for long periods. Stand up and walk every half hour.
5. Getting back to normal
These are usual times. Your own plan is on your card.
| Activity | Small procedure | Flap | Open wound |
|---|---|---|---|
| School or office work | Within a few days | About 2 weeks | Often 1 to 2 weeks |
| Driving | Within a few days | About 2 weeks | When sitting is comfortable |
| Sport and gym | About 2 weeks | About 4 weeks | About 4 weeks |
| Swimming | When healed | When healed | When fully healed |
| Prayer | As usual | Pray on a chair if sitting on the floor hurts | Pray on a chair if needed |
6. Follow-up
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Your follow-up appointment is on your card.
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Come back if the area becomes painful, swollen, or starts to discharge again in the future.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Soreness that improves each week; a little clear or pink discharge; itching as it heals | This is normal. Keep following this guide. |
| AMBER | More redness, swelling, or pain; thick or smelly discharge; temperature of 38 °C or more; part of a closed wound opening | Call us today. |
| RED | Fever with shivering and spreading redness; heavy bleeding; feeling very unwell | Go to the emergency department now. Take this guide with you. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Iesalnieks I, Ommer A, Herold A, Doll D. German National Guideline on the management of pilonidal disease: update 2020. Langenbecks Arch Surg. 2021;406(8):2569-2580.
2. Ojo D, Gallo G, Kleijnen J, et al. European Society of Coloproctology guidelines for the management of pilonidal disease. Br J Surg. 2024;111(10):znae237.
3. Johnson EK, Vogel JD, Cowan ML, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of pilonidal disease. Dis Colon Rectum. 2019;62(2):146-157.
4. Stauffer VK, Luedi MM, Kauf P, et al. Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018;8(1):3058.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.