This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
A pilonidal sinus is a small hole, often full of hairs, found where the buttocks divide; it can become infected and cause pain. People can have a minor procedure to clean the wound, or more major surgery to remove infected skin and tissue. A study involving 667 people with pilonidal sinus found that, compared with tissue-removing surgery, minor procedures were:
- associated with less pain, fewer complications and a faster recovery
- more likely to fail to resolve the condition.
The findings will inform decision-making between clinicians and people considering surgery for their pilonidal sinuses.
More information on pilonidal sinus can be found on the NHS website.
The issue: how effective are different surgical approaches for pilonidal sinus?
Pilonidal sinuses mainly affect younger people (aged 15 to 30), men, and those who are overweight. They often go unnoticed unless they become infected. Infections can cause pain, swelling, and skin abscesses; they can make it difficult for people to sit down.
Abscesses resulting from pilonidal sinuses are usually drained as an emergency. The aim of surgery is then to clean the sinus, encourage healing and avoid further infection. Clinicians may simply scrape out the pilonidal sinus to remove hairs; they may or may not glue the hole closed. Alternatively, they may use a small camera to look inside and clean the hole (endoscopic pilonidal sinus treatment) or use a laser to destroy it.
In more extensive tissue-removing surgery, all affected skin is removed. The wound may be left to heal naturally, or closed using skin flaps from elsewhere on the bottom. Tissue-removing surgeries are usually (but not always) performed on people with more severe disease.
In this study, researchers compared different surgical approaches for pilonidal sinuses.
What’s new?
The study included 667 people with pilonidal sinus disease (aged 16 years or older). Most (73%) were male and their average age was 27. Most (60%) participants had tissue-removing surgery and the rest (40%) had minor procedures. Follow-up data at 6 months was provided by 477 people (71%).
The researchers found that minor procedures were associated with:
- less pain after 7 days (scoring 1.9 on a scale from 0 – 10) compared with tissue-removing surgery (3.4)
- fewer complications (36% of participants) after 6 months compared with tissue-removing surgery (54%)
- a faster return to normal activities (after 7 days) compared with tissue-removing surgery (32 days)
- faster healing (30 days) compared with tissue removing surgery (70 days).
Treatment failure was defined as the need for further surgery, recurrence of pilonidal sinus, or adverse events related to the disease. People who had a minor procedure were around 10% more likely to have treatment failure than those who had tissue-removing surgery.
After 6 months, a quarter of all participants had an unhealed wound and 1 in 10 had not returned to normal activities.
Why is this important?
Minor procedures were associated with less pain, fewer complications and faster recovery than tissue-removing surgery. However, they also had a greater chance of treatment failure. The findings will inform shared decision-making between clinicians and people with pilonidal sinuses.
The findings highlighted the overall high rate of complications after surgery. Tissue-removing surgery was associated with a long period of recovery; minor procedures with a high risk of recurrence. These rates were higher than those reported in other studies. The researchers say more research is needed to improve outcomes and the burden of surgery for people with pilonidal sinuses.
Only 71% of people provided data at 6 months, which reduced the strength of the findings; this was mainly due to the COVID-19 pandemic.
What’s next?
Most participants underwent tissue-removing surgery. The researchers suggest that commissioners and policymakers could ensure that minor procedures are more widely available, and encourage clinicians to discuss potential advantages with people with pilonidal sinuses. A speedy recovery benefits people with pilonidal sinuses, their family, their work and the economy.
In this study, researchers observed the outcomes of different types of surgery but could not conclude which procedures were best. The team is planning a randomised controlled trial to compare different approaches.
The researchers plan to host workshops for surgeons to improve the care of people with pilonidal sinus.
You may be interested to read
This is a summary of: Brown SR, and others. Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation. Health Technology Assessment 2024; 28: 1 - 113.
Other research from the same project: Brown SR, and others. Real-world practice and outcomes in pilonidal surgery: Pilonidal Sinus Treatment Studying The Options (PITSTOP) cohort. British Journal of Surgery 2024; 111. DOI: 10.1093/bjs/znae009.
Information on pilonidal sinus from Patient.
Lived experience of pilonidal sinus on YouTube.
A short video explaining pilonidal sinuses and alternative treatments.
guidelines the latest are due to be published in BJS but have not been yet.
Guidelines due out soon. Ojo D, Gallo G, Kleijnen J et al. European Society of Coloproctology Guidelines for the management of Pilonidal Disease. In press BJS 2024.
A study of patient views on pilonidal sinus surgeries: Strong E, and others. Patient decision-making and regret in pilonidal sinus surgery: a mixed-methods study. Colorectal Disease 2021; 23: 1487 – 1498. And: Banks J, and others. Decision regret following surgical management of pilonidal disease. Colorectal Disease 2024; 00: 1–7.
Funding: NIHR Health Technology Assessment Commissioned Call.
Conflicts of Interest: None relevant.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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