Pilonidal Disease and Hidradenitis Suppurativa

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Pilonidal Disease and Hidradenitis Suppurativa

• Seema Izfar, MD
• 1/18/12

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Pilonidal Disease

• pilonidal disease -subcutaneous infection in
  upper half of gluteal cleft
• can present as an abscess or chronic non-healing
  wound
• typically presents second decade of life
• male female --gt 3-4 1

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Pilonidal Disease
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Pilonidal Disease

• pilonidal cyst - misnomer as it is more
  appropriately a sinus
• pilonidal means hair nest
• first described in 1833 by Mayo

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Corman moment

• in WWII, pilonidal disease hospitalized 79,000
  soldiers for an average hospital stay of 55 days
• such a problem that Surgeon General forbade wide
  local excision as primary therapy

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Pathogenesis

• acquired condision
• observed in hands of sheep shearers and barbers
  implying that shed hairs may initiate the
  condition
• foreign body reaction

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Initial Presentation

• pain, swelling, erythema at top of natal cleft
• acute pilonidal abscess is same as abscess
  anywhere
• chronic pilonidal abscess is an established sinus
  cavity - fails to heal bc of retained hair/fb

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Treatment of Acute Pilonidal Abscess

• excision with acute inflammation not a good idea
• abscess should be drained 1cm lateral to mL -
  excision after healed
• shave hair within 2 inches of gluteal cleft

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Treatment of Chronic Pilonidal Disease

• Nonsurgical
• shaving - duration?
• non-randomized study with retrospective 3yr
  follow-up (Armstrong 1994) with shaving more
  effective with less bed days than surgery

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Pilonidal Disease - Surgical Approaches

• Midline Excision - most frequently performed
  operation for PD, with or without primary closure
• no clear benefit shown between open vs closed
  excision, no benefit to abx

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Pilonidal Disease - Surgical Approaches

• Kronberg 1985 - 88pts randomized to open, closed
  and with or without abx and then followed for 3
  yrs
• recurrence rates not statistically different in
  groups (tendency towards more recurrences in
  primary closure), no benefit to abx
• Fuzum et al - 91 pts randomized to open or closed
• pts left open had lower infection rate (1.8 vs
  3.6) and better outcomes (recurrence 0 vs 4.4)

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Pilonidal Disease - Surgical Approaches

• Unroofing and secondary healing - can allow for
  smaller wounds and faster healing times
• involves unroofing sinus tract without wide, deep
  excision
• recurrence rate 13

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Pilonidal Disease - Surgical Approaches

• Bascom I (chronic abscess curettage and midline
  pit excision)
• lateral debridement from incision 1 cm of the
  midline with excision of midline pits
• closure of pit excision sites
• postoperative shaving at least 1 wk

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Pilonidal Disease - Surgical Approaches

• Bascom procedure

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Pilonidal Disease - Surgical Approaches

• Bascom procedure
• Senapati et al - prospective series 218 pts with
  12 month f/u - overall 90 success, with 10
  requiring further surgery

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Rhomboid flap - cutaneous rotational flap

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Rhomboid cutaneous flap
• large prospective study with 102 pts (regardless
  of severity)
• 6 complication rate (3 seromas, 2 wound
  dehiscence, one wound infection)
• recurrence rate 4.9, pt returned to nml activity
  day 7
• Erdem at al randomized 40 pts with rhomboid flaps
  with drain or no drain - no difference

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Rhomboid cutaneous flap
• overall good results with recalcitrant pilonidal
  disease
• downsides does involve removing large amts nml
  tissue and creates a large scar
• not recommended for disease with chronic abscess
  cavities off the midline - larger defect/flap

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Karydakis flap - developed in 1965 by Greek
  surgeon Dr. Karydakis
• involves excision of vulnerable tissue with
  lateral displacement of wound out of midline
  gluteal cleft
• elliptical incision made parallel to midline,
  diseased tissue excised, lateral advancement off
  the midline

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Karydakis flap

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Karydakis reported results of 7471 pts over 24
  yrs with 2-20 yr f/u and 1 recurrence, 8.5
  complication rate
• no one else has ever studied or reported results
  from this procedure

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Bascom Cleft Lift Procedure (Bascom II) - goal is
  to undermine and obliterate gluteal cleft without
  excision of nomal tissue
• gluteal subcutaneous tissue reapproximated
  underneath the flap, obliterating gluteal cleft

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Bascom studied 28 pts with recurrent wounds with
  this procedure with healing in 22, median f/u 22
  mos

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• V-Y Plasty
• may be applicable to pts that have failed other
  flaps
• Schoeller et al reported 24 pts with mean f/u 4.5
  years with 0 recurrences, 2 wound dehiscences,
  100 eventual healing

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Z-plasty - similar concept
• only one randomized prospective trial in 1981 -
  z-plasty vs open with 100 healing and no
  recurrence on short-term f/u

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Pilonidal Disease - Surgical Approachesfor
Recurrent and Severe Disease

• Peterson et al reviewed 74 articles on
  assymmetric closure techniques
• metanalysis with 38.5 wound infection, 52.4
  wound failure 26.8 recurrence in all pts
  undergoing pilonidal intervention
• only advantage to assymmetric closures with
  decreased recurrence