Pilonidal Sinus (Ingrown Hair) in Children

Sacrococcygeal pilonidal sinus is a formation with small openings in the midline on the sacrum and coccyx (coccyx) that occurs as a result of foreign body granulation initiated by the penetration of hair from the environment into the depth of the coccyx. The Latin words “pilus” meaning hair and ‘nidus’ meaning nest are combined to mean “pilonidal” (nest containing hair).

What are the Causes of Pilonidal Sinus Disease?

The cause of Pilonidal Sinus is not known for certain, but there are some theories that have been put forward. Although it was thought to be congenital in the past, since 1946 it is now accepted that it is an acquired skin disease. This is because it is thought that pilonidal sinus is a chronic foreign body reaction and is caused by the penetration of thin, tight and hard hairs. The surrounding hairs entering the skin start to form a sinus while they are not separated from their roots and form a short canal. The abscess formed as a result of the infection occurring here usually opens to the skin through a canal located laterally on the sacrum. Then a canal extending to the sinus tract is formed.

The fact that it is more common in occupational groups such as drivers, soldiers and students supports the hypothesis that the disease develops with the contribution of factors such as hair density and local microtrauma as well as hormonal predisposition.

Can Pilonidal Sinus Occur in Other Parts of the Body?

Yes, it is seen. Pilonidal sinus is most common in the sacrococcygeal region (coccyx), but it can occur in any part of the body where hair can enter.

It can also occur in other folds of the body, such as in the axilla (armpit), inguinal area (groin), umbilicus (belly button), neck and even between the fingers.

Who is more common and at what age?

Sacrococcygeal pilonidal sinus is more common in young adults, especially in men. Although pilonidal sinus disease peaks between the ages of 16-25, it can be seen at any age, and its incidence gradually decreases after the age of 25. In recent years, it has started to be seen quite frequently in children, especially between the ages of 12-18.

What are the Clinical Symptoms of Pilonidal Sinus?

The most common finding of pilonidal sinus disease is the presence of one or more sinus mouths 3-5 cm above the anus and in the sacrococcygeal (coccygeal) area. A thin soft hairball can be observed coming out of the sinus opening. Because of its proximity to the anal area, the risk of infection is also high. Clinically, there is discomfort, tension and often mucoid discharge. If abscess occurs, classic abscess findings such as discharge, bleeding, redness and extreme pain are observed.

On physical examination; Edema or nodule in the coccyx, midline, fluctuation, purulent discharge from one or more lesions, tenderness on palpation, increased temperature, induration and/or cellulitis (usually minimal). In chronic or recurrent disease, visible or palpable ducts 2-5 cm long, rarely fever, absence of tenderness and/or fluctuations on rectal examination.

How is Pilonidal Sinus Diagnosed?

Diagnosis is based on history and physical examination. Ultrasonography is performed to confirm. Preoperative blood tests are performed. No additional tests are required.

Are There Stages of Pilonidal Sinus?

Yes, there is. And the clinical course of the disease is divided into 4 parts;

1. Pilonidal abscess: The primary cause of an acute pilonidal sinus abscess is blockage of the mouth of the pilonidal sinus by keratin plugs, dead cells or dirt due to poor hygiene. The hair in the sinus triggers a bacterial infection and an abscess forms under the skin.

This is the most common and first manifestation of pilonidal sinus disease. There is swelling, redness, pain and tenderness in the sacrococcygeal region. Fever is usually high and leukocytes are increased.

2. Chronic Pilonidal sinus disease: Occurs when an abscess drains spontaneously or does not heal completely due to poor surgical drainage. Most patients describe a painless discharge. The discharge is continuous or intermittent. On examination, a swelling and firmness is felt in the sacrococcygeal area, which is mildly tender to palpation. In the gluteal cleft, the skin may be slightly depressed and one or more sinus openings (pits) may be present above a dimple. Hair can be seen in this sinus opening or hair can be retained when the inside of the opening is checked with a thin clamp. At this stage, the epithelial tissue moves towards the pilonidal sinus tract.
3. Chronic recurrent pilonidal sinus disease: Occasionally abscesses with acute exacerbations. This abscess is treated by drainage. After recovery, the attack recurs. Apart from the above, these patients have separate, irregular sinus mouths.
4. Perianal pilonidal sinus disease: Over time, as a result of recurrent inflammatory attacks, the sinus can deepen and infiltrate bone tissue, the coccyx and even the sacrum, spreading like a root. Sometimes it can open into the anal canal and rectum, resulting in a complete fistula.

Are There Risk Factors for Pilonidal Sinus Disease?

Studies show that there are some risk factors. These include

• Male gender
• Familial predisposition
• Obesity
• Sedentary lifestyle
• Repetitive trauma
• Occupations that require prolonged sitting

Is There a Clinical Classification of Pilonidal Sinus Disease and If So, What Are They?

Yes, there is.

• Type 1: These patients have no previous history of discharge or abscess and usually do not require treatment. Personal hygiene rules (frequent bathing, clean and cotton underwear, wide and comfortable pants, and avoiding sitting for long periods) and local hair removal (epilation) are recommended for these patients.
• Type 2: Cases with acute pilonidal abscess. These abscesses should be drained through a lateral incision and the hair should be removed. Treatment includes frequent dressing antibiotics and painkillers. This treatment may sometimes require inpatient intravenous treatment. They require definitive surgical treatment after the abscess resolves.
• Type 3: These are cases with a history of abscess drainage or discharge and mouths within the borders of the coccyx region. Surgical treatment can be applied if there is no inflammation. In these patients, the chronic inflamed sinus is first removed and the hair is cleaned as much as possible and surgical procedure is performed.
• Type 4: These are cases in which one or more sinus mouths are outside the borders of the coccyx region. Again, these patients may have active inflammation in some sinus mouths. These patients have a history of multiple episodes of abscess formation, drainage and discharge. Surgery is performed after the infection is treated.
• Type 5: Cases with recurrence after pilonidal sinus surgery. The main reason for the failure of the previous attempt is inadequate excision of the sinus due to inadequate determination of the sinus width in the coccyx region of the patient. It requires a second surgical procedure.

Is it Necessary to Clean the Hair of the Area Before Treatment in Pilonidal Sinus Patients?

It is known that cleaning the hair of the area with laser or other methods reduces recurrence. However, if cleaning is to be done with razor blades or similar methods, cleaning should be done on the operating table before surgery. Thus, infection transmission through the incisions on the skin is prevented.

How to Treat Pilonidal Sinus Disease in Children?

Treatment of patients without complaints:

Very small dimples in the sacrococcygeal region found in children or young adults do not require treatment. If there are no signs of inflammation or infection in this area, ultrasound is performed and if no pathology is detected, these patients can be followed up.

Treatment of acute pilonidal abscess:

The treatment of acute pilonidal abscess is to drain the abscess urgently. The procedure is performed under local or general anesthesia depending on the patient's condition. The abscess is usually on the right or left side of the midline. Therefore, the drainage incision should be lateral to the midline. The abscess is drained from the center of the fluctuating area with a fine-tipped scalpel. The abscess wall is curetized to prepare the ground for secondary healing. Following hemostasis, the abscess cavity is closed with wet gauze. A broad-spectrum antibiotic is started for the treatment of cellulitis in the surrounding tissue. Antibiotic is changed if necessary according to culture and antibiogram results. Dressings are applied at frequent intervals.

Although the success of the treatment depends on the meticulousness of the dressings, in 30-50% of patients the abscess recurs or chronic sinus develops. Therefore, these patients should be surgically corrected after treatment of the abscess.

What are the Main Treatment Options in Chronic Pilonidal Sinus Disease?

Since these patients have a high risk of recurrence after treatment, there is no consensus on a treatment method. Many treatment methods have been defined in this regard.

Conservative methods:

1. Injection of sclerosing agent: Phenol administration in particular is defined as a conservative method in the treatment of pilonidal sinus and is the first choice of treatment in some clinics. It is the most widely used conservative method, consisting of the injection of phenol into the sinus. Phenol has antiseptic, anesthetic and potent sclerosing properties. At room temperature, it is a white crystallized solid, whereas at higher temperatures it can change to liquid form. Phenol is used in liquid or crystallized forms in the treatment of pilonidal sinus disease. In this method, the sinus mouth is expanded, the contents are cleaned and all hairs are removed with a clamp. Then 2-3 ml of 80% phenol is injected into the pilonidal sinus while preserving healthy skin. The aim of the method is to irritate the inner wall of the sinus cavity with phenol, a sclerosing agent, and to fill it with granulation tissue.

In addition to phenol, cauterization of the cavity, silver nitrate, 80-90% alcohol and fibrin glue have also been used for this purpose.

However, it should be kept in mind that the risk of recurrence of pilonidal sinus is high in this application.

2. Cryosurgery: It is based on the destruction of the pilonidal tract by cryosurgery. This method involves opening the tracts and their side branches, curettage and electrocoagulation of bleeding points. The open wound is then sprayed with liquid nitrogen for about five minutes. Some publications have reported less scarring and deformity with this method compared to wide excision. It has a high recurrence rate.

3. Radiotherapy: It is not recommended due to the high risk of radiation necrosis and onset of tumoral processes.

Is There a Place for Laser in Pilonidal Sinus Treatment?

Laser is used from time to time, but its use is still controversial.

What is Endoscopic Pilonidal Sinus Treatment?

An endoscopic device with a camera at the end is inserted into the cyst through the cyst opening. After the cyst is completely cleaned, the cyst wall is thermally burned. Since the method is painless, patients can easily return to social life. However, the recurrence rate is high, so it can be applied in selected patients.

Surgical techniques:

Although many surgical treatment methods have been described for pilonidal sinus, there is no ideal treatment method due to recurrence rates. The basic principle of surgical treatment is to excise the lesion with safe margins and to choose a technique that minimizes the possibility of recurrence. The main problem of surgical technique is how to close the resulting cavity.

What are the Considerations in the Surgical Treatment of Pilonidal Sinus Disease?

• Scar tissue should not be in the midline
• There should be no dead space in the wound
• The wound should heal without infection
• Regardless of which surgery is performed, the sacrococcygeal area should be cleaned of hair regularly and intermittently after surgery and the body should be cleansed of hair loss by bathing every day
• There are publications showing that laser hair removal in this area contributes to the healing of the disease.

How is Pre-Surgical Preparation and Operative Positioning Performed?

The presence of infection, inflammation in and around the sinus or complications such as cellulitis in patients to be operated on requires postponement of surgical treatment. This should be treated with anti-inflammatory drugs and antibiotics if necessary.

Surgery can be performed under general anesthesia or regional anesthesia. Regional anesthesia should not be used in patients with cellulitis or infection.

Preoperative antibiotic treatment is started. The patient is fasted for 4 hours before surgery.

What are Pilonidal Sinus Surgical Techniques in Children?

Surgical techniques used for this purpose are briefly as follows:

1. Sinus excision + secondary healing: The easiest method of surgery in patients with chronic pilonidal sinus is to excise the sinus roof, convert the lesion into an open wound and leave the wound to secondary healing. It is the method with the lowest chance of recurrence. However, the patient comes to the hospital every day or every 2 days for dressing for a long time, sometimes for months, and the social life of the patient is negatively affected during this period. This procedure is performed under general anesthesia in the operating room in children.
2. Pilonidal Sinus Excision and Secondary+Primary Repair: In this method, the cyst is completely excised (removed) and the wound openings are closed with primary sutures. It is performed under general anesthesia and is a simple and cosmetically good method. The recurrence rate is quite high, so it can be applied in selected patients.
3. Feb Techniques; There is no consensus on the treatment of Pilonidal Sinus in case of recurrence. Many flap methods have been defined in this regard. Here, in order not to cause anxiety in patients and families, the Limber Flap and Modified Limberg method, which is the most accepted method (the method with the lowest rate of complication and recurrence) in adults and children in the world, will be mentioned.
4. Limberg Flap For the Limberg flap, the borders of the incision are drawn as a rhombus (ABCD), provided that all sinus orifices remain within it. The side to be flapped is marked as a continuation of the rhombus and the sides of the rhombus are equal in length (DE). From point E, it is marked downward and of equal length, again parallel to the lateral edge of the rhombus (EF). The flap can be on either lateral, superior or inferior side of the rhombus. When flap nutrition and cosmetic aspects are considered, flaps rotated from below give better results.

   

    

5. Modified Limberg Flap; This method can be applied in children for the first time in the world and it has been shown with our scientific study that recurrence is reduced. In this method, incisions do not come to the midline and recurrences are prevented.

   

   

    

The cosmetic appearance is not good but the recurrence rate is quite low. It is a necessary method to be preferred in pilonidal sinus treatment.

How to Care for the Patient After Pilonidal Sinus Surgery?

• The patient can take food by mouth within 1-2 hours after surgery and does not need intravenous fluids after 5-6 hours.
• Analgesics are started before the effect of spinal anesthesia ends and repeated every 4-6 hours.
• The drain at the operation site is removed after 1 day if no one comes.
• The patient is sent home on the 1st or 2nd day depending on his/her condition.
• The patient is free to walk, sit on the wound and lie on his/her back.
• Antibiotics and painkillers are recommended for the first 5 days.
• The wound can remain open after the 2nd day.
• The patient can take a shower after the 5th day.
• After two weeks, the stitches are removed and the patient can return to social life.
• After the operation, the hairs in the operation areas are cleaned periodically for 6 months.
• The patient pays attention not to sweat after the operation, if he/she sweats, he/she takes a shower immediately
• The patient pays attention not to sit for a long time for 6 months after the operation, he/she does not sit during classes and between classes
• He/she takes a walk.
• The patient should be careful not to get wet and dry after bathing, sea and pool.

*** The information provided herein is intended to inform the visitor of the content of the website. No information should be considered as advice by visitors and should not lead to any decision or action. Families should have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her knowledge.