By the WoundSource Editors
Chronic wounds pose an ongoing challenge for clinicians, and there needs to be a clearer understanding of the pathophysiology of wound chronicity and treatment modalities available.
By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN
A pilonidal cyst is a pocket located at the top of the cleft of the buttocks that usually results from an embedded or stiff hair. This area may remain dormant for years and cause no major issues; however, often the embedded or stiff hair may cause the cyst to become inflamed and infected, resulting in an abscess that requires incision to drain the infected material. These abscesses can recur, causing the patient to require surgical intervention to remove the cyst. After surgery, some patients tend not to heal well, resulting in a chronic tracking wound in an area that is difficult to heal.
Risk factors for pilonidal cyst include family history, sedentary job, extensive body hair, smoking, and obesity. It is more common among younger adults, with men affected three to four times more often than women. Friction from clothing, tight clothing, or sitting for prolonged periods may also cause the area to become inflamed.
Why are these wounds so difficult to heal? Location, offloading, pressure from clothing, and cleansing are issues that can impede the healing of a pilonidal cyst. It is not uncommon for up to 50% of pilonidal cysts to recur.
Initially, treatment of the pilonidal cyst involves incision and drainage of the area. Oral antibiotics are not usually required given that the infection is localized. After the area has been incised, wound care involves daily irrigation with sterile water or wound cleanser in a syringe and packing of the wound because the wound will need to heal from the base up. As the wound begins to heal, less packing will be required. It is important to fill the wound and to not pack tightly because this can impede healing. It is important to ensure that the patient has a caregiver who can assist with wound care because these wounds are usually difficult for the patient to manage, given the location. The greatest impact on healing is offloading. Make sure the patient understands that he or she needs to keep pressure off the area while it is healing, as well as avoiding shear and friction. The patient should avoid prolonged sitting and tight clothing. Moisture management is also important and can be achieved with an absorptive dressing unless the patient has a large amount of drainage, which may require negative pressure. No tub baths should be taken while the wound is healing or acutely inflamed.
Once the wound is healed, the patient must be educated on methods to help prevent the recurrence of pilonidal cysts. The patient should be educated on cleansing techniques, hair removal, offloading, and clothing choices. The patient needs to be educated that keeping the area clean is very important. The patient may use cleansing wipes after toileting. Some infectious disease doctors recommend chlorhexidine showers twice weekly, leaving the chlorhexidine in place for one minute and then rinsing. Many patients benefit from laser hair removal. The patient has to understand the importance of offloading and avoiding prolonged sitting because this is a major risk factor, as outlined earlier. The patient should avoid clothing that can cause friction and pressure such as jeans or tight non-breathable clothing, as well as thongs.
What if the cyst does not close after surgery? Sometimes failure to close after surgery may result in the patient's having to return to surgery. Returning to surgery can complicate issues related to increased scar tissue, which does not heal as well as normal tissue. If surgical revision is not an option or has been attempted more than once with no closure of the wound, the goals for this wound then become to manage infection, attempt to reduce or maintain size of wound, provide appropriate dressing materials that optimize ease of care, minimize pain through the use of comfortable dressings and topical anesthetics, and routinely monitor the wound. Advanced therapies may also be utilized to reduce the size of the wound. The patient's nutrition should be addressed to ensure that he or she is eating the proper foods and getting adequate hydration. As with any non-healing wound, a wound culture would be warranted, as well as a biopsy, to rule out any malignancy. Other comorbidities should be addressed such as diabetes, smoking, and the use of anticoagulants.
Almajid FM, Alabdrabalnabi AA, Almulhim KA. The risk of recurrence of pilonidal disease after surgical management. Saudi Med J. 2017;38(1):70–4.
Fahrni GT, Vuille-dit-Bille RN, Leu S, et al. Five-year follow-up and recurrence rates following surgery for acute and chronic pilonidal disease: a survey of 421 cases. Wounds. 2016;28(1):2–6.
Marza L. Reducing the recurrence of pilonidal sinus disease. Nurs Times. 2013;109(25):22–4.
Mayo Clinic. Pilonidal cyst. 2018. https://www.mayoclinic.org/diseases-conditions/pilonidal-cyst/symptoms-c.... Accessed December 30, 2018.
About the Author
Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN is a Nurse Practitioner at the VA Medical Center in Lake City, Florida. She is the Wound Care Provider in the Out-Patient Clinic serving the Veteran Population of North Florida and South Georgia. Cathy is certified in wound, ostomy and foot care. In addition to her wound care experience, she also has experience in acute care, pediatrics, home health, long-term care and has served as a Professor of Nursing. Cathy’s passion for wound care began while she was working in the long-term care setting as an RN. She serves the veteran population as a memorial to her dad, a combat wounded WWII Veteran.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.