Pilonidal Cyst
A painful cyst that develops in the skin near the tailbone, often containing hair and debris
Quick Facts
- Type: Skin Condition
- ICD-10: L05
- Location: Tailbone area
- Common in: Young adults
Overview
A pilonidal cyst is a painful condition that occurs in the skin near the tailbone (coccyx), typically in the groove between the buttocks. The term "pilonidal" literally means "nest of hair," as these cysts often contain hair and skin debris. These cysts can form when hair follicles become blocked and infected, creating a pocket of tissue that fills with fluid, pus, and other debris.
Pilonidal cysts are most common in young adults, particularly men, and those who sit for long periods or have jobs that involve prolonged sitting. The condition can range from a small, painless pit in the skin to a large, painful abscess that requires immediate medical attention. While some pilonidal cysts may remain asymptomatic for years, others can become severely infected and cause significant discomfort.
The condition is also known as pilonidal disease or pilonidal sinus when it involves a channel or tract connecting the cyst to the skin surface. Treatment typically involves surgical drainage and removal, though the specific approach depends on the severity and location of the cyst. With proper treatment, most people recover completely, though there is a risk of recurrence if preventive measures aren't taken.
Pilonidal cysts can significantly impact quality of life, making sitting, walking, and normal daily activities uncomfortable or painful. Early recognition and treatment are important to prevent complications such as chronic infection, abscess formation, or the development of multiple interconnected cysts.
Symptoms
The symptoms of pilonidal cyst can vary greatly depending on whether the cyst is infected and the severity of the condition. Many people may have a pilonidal cyst for years without symptoms, while others experience sudden onset of severe pain and infection.
Common Symptoms
Additional Symptoms
- Generalized aching in the lower body
- Lower body pain that worsens with sitting
- Bone pain in the tailbone area
- Irregular skin appearance near the cyst
- Tenderness when pressure is applied to the area
- Redness and warmth around the cyst
Signs of Infection
When a pilonidal cyst becomes infected, additional symptoms may include:
- Drainage of pus or blood from the cyst
- Foul-smelling discharge
- Fever and chills
- Increased pain and swelling
- Red streaks extending from the cyst
- Formation of multiple openings or sinuses
- Hair protruding from the cyst opening
Chronic Symptoms
In chronic cases, symptoms may include:
- Persistent drainage
- Recurring episodes of pain and swelling
- Multiple cyst formations
- Difficulty sitting or lying on the back
- Scarring and thickened skin in the affected area
Causes
The exact cause of pilonidal cysts is not fully understood, but several factors contribute to their development. The condition appears to result from a combination of hair penetration into the skin and mechanical factors that create favorable conditions for cyst formation.
Primary Causes
- Hair follicle irritation: Constant friction and pressure can cause hair follicles to become irritated and infected
- Hair penetration: Loose hairs can work their way into small breaks in the skin, creating a foreign body reaction
- Blocked pores: Dead skin cells and debris can block hair follicles, leading to cyst formation
- Trauma or injury: Minor injuries to the tailbone area can create entry points for hair and bacteria
Contributing Factors
- Prolonged sitting: Extended periods of sitting create pressure and friction in the tailbone area
- Poor hygiene: Inadequate cleaning of the area can allow bacteria and debris to accumulate
- Tight clothing: Clothing that creates friction or doesn't allow air circulation
- Excessive sweating: Moisture can soften the skin and make hair penetration easier
- Deep natal cleft: A deeper groove between the buttocks can trap hair and debris
Mechanical Factors
Several mechanical factors can increase the likelihood of pilonidal cyst development:
- Repetitive motion that causes hair to drill into the skin
- Pressure from sitting that forces hair into small skin openings
- Shearing forces from movement while sitting
- Suction created by body movement that draws hair into skin pits
Secondary Infections
Once a pilonidal cyst forms, it can become infected with various bacteria, including:
- Staphylococcus aureus
- Streptococcus species
- E. coli
- Anaerobic bacteria
Risk Factors
Several factors can increase the likelihood of developing a pilonidal cyst. Understanding these risk factors can help with prevention and early recognition of the condition.
Demographic Risk Factors
- Age: Most common in people aged 15-40, with peak incidence in the twenties
- Gender: Men are 3-4 times more likely to develop pilonidal cysts than women
- Family history: Genetic predisposition may play a role in some cases
- Ethnicity: More common in people of Caucasian descent
Physical Risk Factors
- Excessive body hair: Particularly thick, coarse, or curly hair in the sacral area
- Deep natal cleft: A deeper groove between the buttocks
- Obesity: Excess weight can increase pressure and friction in the tailbone area
- Body hair growth pattern: Hair that grows toward the natal cleft
Lifestyle Risk Factors
- Prolonged sitting: Jobs or activities requiring long periods of sitting
- Sedentary lifestyle: Lack of physical activity
- Poor hygiene: Inadequate cleaning of the sacral area
- Tight clothing: Clothes that create friction or trap moisture
- Frequent driving: Long-distance drivers or truck drivers
Occupational Risk Factors
- Truck drivers and taxi drivers
- Office workers who sit for extended periods
- Military personnel (historically called "jeep seat")
- Hair stylists and barbers (due to exposure to loose hair)
- Dog groomers and sheep shearers
Medical Risk Factors
- Previous pilonidal cyst: History of pilonidal disease increases recurrence risk
- Immunocompromised state: Conditions that weaken the immune system
- Diabetes: May impair healing and increase infection risk
- Local trauma: Previous injury to the tailbone area
Diagnosis
Diagnosing a pilonidal cyst typically involves a physical examination and review of symptoms. Most cases can be diagnosed based on clinical presentation, though additional tests may be needed in complex cases.
Clinical Examination
The diagnosis is usually made through:
- Visual inspection: Looking for pits, openings, or swelling near the tailbone
- Physical examination: Palpating the area to identify cysts, tenderness, or fluid collection
- Medical history: Discussing symptoms, onset, and risk factors
- Assessment of drainage: Examining any discharge for signs of infection
Diagnostic Criteria
Healthcare providers look for:
- One or more pits or openings in the natal cleft
- Hair protruding from the openings
- Swelling or inflammation in the sacrococcygeal area
- Tenderness or pain with pressure
- Signs of infection such as redness, warmth, or drainage
Differential Diagnosis
Conditions that may be confused with pilonidal cyst include:
- Perianal abscess: Infection near the anus
- Hidradenitis suppurativa: Chronic skin condition with similar symptoms
- Dermoid cyst: Congenital cyst containing skin elements
- Furuncle or carbuncle: Bacterial skin infections
- Crohn's disease: Can cause fistulas in the perianal area
Additional Tests
In complex or recurrent cases, additional tests may include:
- MRI or CT scan: To evaluate the extent of the disease and identify multiple tracts
- Ultrasound: To assess fluid collections and guide drainage procedures
- Culture testing: To identify specific bacteria and guide antibiotic treatment
- Sinography: Injection of contrast material to map sinus tracts
Classification
Pilonidal disease is often classified as:
- Acute: Recent onset with active infection
- Chronic: Long-standing disease with persistent symptoms
- Complex: Multiple openings and interconnected tracts
- Recurrent: Return of symptoms after previous treatment
Treatment Options
Treatment for pilonidal cysts depends on the severity of symptoms, whether infection is present, and if the condition is acute or chronic. Options range from conservative management to various surgical procedures.
Conservative Treatment
For small, asymptomatic cysts, conservative management may include:
- Regular hair removal: Shaving or laser hair removal to prevent hair accumulation
- Improved hygiene: Daily cleaning with antibacterial soap
- Warm compresses: To reduce pain and promote drainage
- Weight management: Reducing pressure on the affected area
- Avoiding prolonged sitting: Taking regular breaks from sitting
Medical Treatment
- Antibiotics: For infected cysts, typically including coverage for both aerobic and anaerobic bacteria
- Pain management: NSAIDs or other pain relievers
- Antiseptic solutions: Topical treatments to prevent infection
- Phenol injection: Chemical treatment to destroy the cyst cavity
Surgical Procedures
Drainage Procedures:
- Incision and drainage: For acute abscesses, provides immediate relief
- Needle aspiration: For smaller fluid collections
- Unroofing: Opening and cleaning the cyst cavity
Definitive Surgical Treatment:
- Simple excision: Removal of the cyst and surrounding tissue
- Wide local excision: More extensive removal for complex cases
- Marsupialization: Opening the cyst and suturing edges to create a pouch
- Flap procedures: Using tissue flaps to close large defects
Wound Closure Options
- Primary closure: Direct suturing of the wound
- Secondary healing: Allowing the wound to heal naturally
- Delayed primary closure: Closing the wound after several days
- Skin grafts: For very large defects
Post-Operative Care
- Wound care and dressing changes
- Antibiotic therapy if indicated
- Pain management
- Activity restrictions during healing
- Regular follow-up appointments
- Hair removal in the surrounding area
Recovery Timeline
- Simple drainage: 1-2 weeks for initial healing
- Excision with primary closure: 2-4 weeks
- Open healing: 6-12 weeks or longer
- Complex procedures: 3-6 months for complete healing
Prevention
While not all pilonidal cysts can be prevented, several strategies can significantly reduce the risk of developing this condition or prevent recurrence after treatment.
Hair Management
- Regular hair removal: Shaving, waxing, or using depilatory creams in the sacral area
- Laser hair removal: Permanent reduction of hair growth in the affected area
- Professional grooming: Regular visits to remove excess hair
- Proper shaving technique: Using sharp razors and shaving in the direction of hair growth
Hygiene Practices
- Daily cleansing: Washing the area with antibacterial soap
- Thorough drying: Ensuring the area is completely dry after bathing
- Regular bathing: Especially after sweating or physical activity
- Gentle cleansing: Avoiding harsh scrubbing that could damage the skin
Lifestyle Modifications
- Limit prolonged sitting: Take breaks every hour to stand and move
- Use cushions: Specialized cushions to reduce pressure on the tailbone
- Maintain healthy weight: Reduce excess pressure on the sacral area
- Stay active: Regular exercise to improve circulation and reduce sitting time
Clothing Choices
- Loose-fitting clothes: Avoid tight garments that create friction
- Breathable fabrics: Cotton and moisture-wicking materials
- Proper underwear: Well-fitting, breathable underwear
- Change clothes regularly: Especially after sweating
Workplace Modifications
- Ergonomic seating: Proper chair support and positioning
- Standing desk options: Alternating between sitting and standing
- Regular breaks: Scheduled breaks from sitting
- Seat cushions: Specialized cushions for long periods of sitting
Post-Treatment Prevention
For those who have been treated for pilonidal cysts:
- Continue hair removal indefinitely
- Maintain excellent hygiene
- Follow all post-operative instructions
- Regular follow-up appointments
- Early recognition of recurrence symptoms
- Lifestyle modifications as recommended
When to See a Doctor
Knowing when to seek medical attention for a suspected pilonidal cyst is important for preventing complications and ensuring proper treatment.
Seek Immediate Medical Attention
- Severe pain: Intense pain that interferes with daily activities
- Signs of systemic infection: Fever, chills, or feeling unwell
- Rapidly spreading redness: Red streaks extending from the cyst
- Large abscess: Significant swelling with fluctuance
- Inability to sit or walk: Severe functional impairment
- Profuse drainage: Heavy bleeding or pus discharge
Schedule an Appointment
- Persistent pain: Ongoing discomfort in the tailbone area
- Visible pit or opening: Small holes or dimples near the tailbone
- Recurrent episodes: Repeated episodes of pain and swelling
- Drainage: Any discharge from the affected area
- Swelling: Noticeable lump or bump near the tailbone
- Hair protruding: Hair visible coming from skin openings
Follow-up Care
Regular follow-up is important for:
- Monitoring healing after treatment
- Assessing for recurrence
- Adjusting preventive measures
- Managing any complications
- Wound care guidance
What to Expect During Your Visit
- Physical examination of the affected area
- Discussion of symptoms and their duration
- Review of risk factors and lifestyle
- Possible imaging studies if indicated
- Treatment plan discussion
- Instructions for home care
Questions to Ask Your Doctor
- What treatment options are available?
- What are the risks and benefits of surgery?
- How can I prevent recurrence?
- What should I do for wound care?
- When can I return to normal activities?
- What signs should prompt immediate medical attention?
References
- Iesalnieks I, Fürst A, Rentsch M, Jauch KW. Primary midline closure versus open wound healing in pilonidal sinus disease. Int J Surg. 2010.
- Al-Khamis A, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2010.
- Sondenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995.
- Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary closure techniques in chronic pilonidal sinus. Dis Colon Rectum. 2005.
- McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus. BMJ. 2008.