Pilonidal Cyst

A pilonidal cyst is a sac or pocket that forms around a hair follicle and contains hair and debris of the skin along with fluid. It is located at the end of the coccyx (tailbone) between the cheeks of the buttocks.

The cyst may soon progress to infection and become painful and tender. The cyst fluid may progress to be replaced by pus and is then called a pilonidal abscess.

If left untreated, the abscess ultimately ruptures due to the intense pressure of the pus in the sac and the pus drains out by creating a pilonidal sinus (a blind tract that starts from the abscess and opens up to the outside skin). Following the sinus development, the swelling and pain may reduce but the focus of infection is still present and, hence, the sinus continuously discharges pus.

The symptoms of the cyst can be irritating and interfere with daily activities. These include:

• Pain while sitting, especially if pressure is being applied to the tailbone
• There can be pain on bending, squatting or lower back pain
• Swelling in the tailbone area, between the creases of the buttocks
• Pain and tenderness on the swelling along with redness around the area
• When the abscess develops, the pain may become unbearable. Fever and generalised tiredness are seen
• Pus and blood discharge may be present when the cyst ruptures
• A tiny hole may be present in the skin (opening of the sinus) which may discharge pus and blood. It may be associated with a foul smell
• In chronic and recurring cysts, many sinuses may be present (with or without discharge) in the area

Earlier, the cysts were thought to be congenital (i.e., present from birth) but become symptomatic later in life.

During World War II, more than 80,000 soldiers were hospitalised due to the development of the cyst. These soldiers often used to drive or ride in military jeeps and the cyst was caused due to the bumpy rides. Hence, the disease also came to be known as jeep disease.

Newer research and studies indicate that the cyst develops due to the ingrowth of hair into the skin. This causes blockage of the hair follicle and, hence, leads to the development of the cyst.

Various factors are thought to be responsible for the cyst. These include:

• Age: it is commonly seen in ages between 20 and 30
• Gender: more common in males than females (4 times more common)
• Family history: if a person has parents or immediate relatives with a history of pilonidal cyst, the risk of acquiring the cyst for them increases
• Obesity: obese individuals are more prone to develop the cyst
• Body hair: naturally hairy individuals especially near the buttocks are at a higher risk of developing the disease
• Sedentary lifestyle: prolonged hours of sitting is a risk factor
• Friction from clothes: not wearing undergarments and irritation from rough clothing poses a risk of developing the cyst
• History of a pilonidal cyst

Pilonidal cysts do have a genetic predisposition. Hence, they may not always be prevented. However, some measures can be taken to prevent cyst development or recurrence. These include:

• Washing and keeping the area around the buttocks clean
• Avoid sitting for prolonged times. In case this cannot be avoided, use a doughnut-shaped cushion to prevent pressure on the tailbone
• In obese individuals, weight loss is advised
• Shaving the area around the buttocks or using a hair removal cream to prevent the ingrowth of hair. A newer and more permanent approach is laser removal of hair.
  
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As such no specific tests are required to diagnose a pilonidal cyst. It is based on a local examination of the area by the doctor. During the examination, the doctor will see the following:

• Location of the swelling
• Size of the swelling
• Skin changes over the swelling such as redness or hardening of the skin
• Tenderness over the swelling
• Any discharge from the swelling
• The number of sinuses, if present, and whether they are presenting with discharge

In chronic and recurring cysts, a swab of the discharge is taken and sent for microbiological evaluation to determine the cause of infection and antibiotic sensitivity. Additionally, if sinuses are present a CT or MRI may be done to find out the depth of the sinus.

A pilonidal cyst is to be treated to prevent the progression of the disease and to avoid further complications. Treatment can be under the following two approaches:

1. Medical intervention (conservative method)

This is the non-surgical approach to treating the cyst. It is beneficial in the early stages of the cyst when the infection has just started. The measures taken are:

• Sitz baths: soaking the area in warm water for 15 to 20 minutes, 2 to 3 times a day gives relief from the pain and may help reduce the swelling by increasing the blood circulation in the area
• Antibiotics and pain medications as prescribed by the doctor
• Dietary supplementation of zinc and vitamin C may help in the healing process
• Essential oils, such as tea tree oil, have shown antibiotic properties and may help in the healing of the cyst
• Phenol injections: in this method, the doctor injects antiseptic phenol into the cysts on repeated visits till the cyst disappears

It is to be noted that conservative interventions are often not curative and there is a high risk of recurrence.

2. Surgical intervention

This is a more definitive mode of treatment with a lower rate of recurrence. It involves either of the following two methods:

• Incision and drainage: in this method, a simple incision is made and the contents of the cyst are squeezed out. The method may not completely remove the focus of infection.
• Pilonidal cystectomy: this is a minor surgical procedure in which the cyst is completely removed along with the sinus tract (if present). This has the highest success rate in treatment with the lowest risk of recurrence.

(Read more: Pilonidal cyst surgery)

A pilonidal cyst in itself is not fatal. However, if left untreated, it can cause numerous adverse health effects such as:

• The condition may progress to a chronic disease with numerous sinuses
• The local infection from the cyst may progress to a systemic infection, especially in immune-compromised individuals.
• In extremely rare cases, chronic infection may progress to a type of skin cancer known as squamous cell carcinoma.

In conclusion, pilonidal cysts are a common occurrence in the population. Since they develop in private areas, often they are not treated until complications develop. Young hairy males are more prone to develop the condition. The cyst is associated with symptoms that are painful and interfere with daily life activities. If untreated, they may progress to more serious complications. There are numerous modalities of treatment among which the surgical removal of the cyst shows the best results. Various measures can be employed to prevent cysts from occurring. However, despite preventive and surgical measures recurrence of the cyst is quite common.