Introduction

Pilonidal sinus is a disease of easy handling and difficult healing.

It is a common problem in primary care due to recurrence following surgery and the need for frequent and time-consuming wound care. This article covers the pathology, clinical presentations and appropriate management of pilonidal sinus disease.₁

The patient was treated here had been operated three times before coming to the author. He was operated in his country twice and in Kuala Lumpur once. His sinus was in the natal cleft.

Review of literature

How does it develop?

Theory 1: A minor congenital or hereditary abnormality in the skin of the natal cleft as it tends to run in some families.

Part of the abnormality in this part of the skin may be that the hairs grow into the skin rather than outwards.

Theory 2: abnormal hair growth direction. Hair is forced to grow in abnormal direction.₂,₃

Author theory 3: Lack of cleaning of this moist area with development of a small boil or furuncle which will open with long hairs around will come in and keep growing inside making a long track of granulation tissue.

(A similar condition occurs between the fingers of hairdressers caused by customers' hair entering moist, damaged skin.)

Recurrent disease

Recurrence can be divided into two groups: early and late. Early recurrence is usually due to failure to identify one or more sinuses at incision and drainage, which was not followed by a second-look procedure. Late recurrence is usually due to secondary infection caused by residual hair or debris that was not removed at operation, inadequate wound care or insufficient attention to depilation.₄

Case data

29 years old male was presented to the author with the recurrent pilonidal sinus after three previous operations. All operations failed to achieve proper healing.

Methods

Patient was operated by a closed method where the track was excised with an elliptical incision and excision of bad part of skin.

The track had two openings one above and one below in the natal cleft.

After excision of the track the two edges were approximated and closed. Simple closure of the two edges of the wound with vicreyl 1, and skin was closed by Nylon 3/0. The wound was left partially open in its upper part to heal spontaneously.

Post operatively: patient was instructed to sleep prone position for few days. Hyperbaric oxygen was used in 5 sessions to accelerate healing. Bovidone iodine was used frequently for cleaning during dressing. Suture removal was done one week after surgery.

Results

It was very promising where the sinus was healed after one month from surgery. At the beginning the surrounding hairs tended to cause recurrence by being imbedded into the lower part of the incision of the natal cleft. Fig 3

The author immediately shaved the hairs around the natal cleft and one week after the wound was completely healed. Fig 4

Figure 1

Figure 1 upper end of the track is shown by the arrow

Figure 2

Figure 2: The track has another opening in the lower part of the cleft

Figure 3

Figure 3: Post operative a new opening lower down helped by hairs around

Figure 4

Figure 4: Complete healing one week after hair shaving

Discussion

Treating this recurrent problem may appear difficult. We excised the main track of the sinus which appeared here as a fistula with two openings one above and one below in the natal cleft. It measured 10 cm long between the two openings. Elliptical skin part is removed containing the upper opening and the scarred skin around. Healing was not perfect when hairs were around the natal cleft and tended to come in the wound at the lower pole of the natal cleft incision line.

Shaving of hairs around the natal cleft affected the healing very well and in a week time the wound was completely closed.

Conclusion

Cleaning is mandatory for effective closure of the sinus. Excision of the track is the main item of treating the sinus. Hair removal is a complementary step to ensure cure.

Open or close techniques are of the same result where the closed technique tend to heal faster.