​Kembara Xtra - Medicine - Pilonidal Disease

​Kembara Xtra - Medicine - Pilonidal Disease
Pilonidal illness is brought on by a sinus tract or abscess in the upper portion of the natal (gluteal) cleft.
Alternative name(s): Jeep illness

Epidemiology 
Incidence: 16–26/100,000 annually; males outnumber women (3–4:1)
 Whites are given preference over Blacks and Asians in terms of ethnicity. Predominant age: 2nd to 3rd decade, unusual >45 years
Prevalence
Male to female ratio in surgical procedures is 4:1, but incidence data are 10:1.

Pathophysiology and Etiology 

Pilonidal, which means "nest of hair," refers to hair in the natal cleft that allows for the creation of a pilonidal cyst through follicular occlusion (stretching of the hair follicles) and pore obstruction (covering of pores with debris) (50%).
 Polymicrobial, probably from enteric pathogens given closeness to anorectal contamination Inflammation of SC gluteal tissues with secondary infection and sinus tract development
Genetics: Follicular-occluding tetrad of acne conglobata, dissecting cellulitis, hidradenitis suppurativa, and pilonidal lesions; congenital dimple in the natal cleft/spina bifida occulta


Risk factors include being sedentary or spending a lot of time sitting down, having excessive body hair, being overweight, and having a congenital indentation in the coccyx.

Trim hair in and around the gluteal cleft on a weekly basis.
Prevention of ingrown hairs and follicle unblocking


Diagnosis 

three unique clinical manifestations
Asymptomatic: a sinus or cyst at the top of the gluteal cleft that causes no pain; fever is uncommon.
Acute abscess symptoms include intense pain, swelling, and a discharge coming from the top of the gluteal cleft that may or may not have naturally emptied.
continuous leakage from a sinus tract at the apex of the gluteal cleft indicates a chronic abscess.

clinical assessment 

Common: an inflamed cystic mass at the apex of the gluteal cleft with minimal surrounding erythema, drainage, or a sinus tract; uncommon: an infected sinus with one or more pits and hair debris; less common: severe cellulitis of the nearby tissues.

Differential diagnoses include folliculitis or furunculosis, anal fistula, perirectal abscess, and Crohn's disease.

Laboratory Results 

Typically, no tests are required because a clinical diagnosis can be made.
Consider CBC and wound culture as initial tests (lab, imaging), albeit they are typically not required for less serious infections.
To discriminate between perirectal abscess and pilonidal illness, ultrasound or MRI may be used.
Tests in the Future & Special Considerations
If an infection is suspected, no diagnostic procedures or other wound cultures are used.


Shave the region; weekly hair removal from crypts.

If antibiotics are required, a culture to guide therapy may be helpful. Antibiotics are not recommended unless there is extensive cellulitis.
If cellulitis is suspected, cefazolin plus metronidazole or amoxicillin-clavulanate are frequently utilized as an empirical treatment.

Referral: Patients with complex diseases involving many sinus tracts, patients who are unable to keep up with the required number of dressing changes after incision and drainage (I&D), and patients who have recurrence after I&D

Further Therapies 
I&D with only enough packing to allow the cyst to drain; overpacking is not advised. Antibiotics only if there is significant cellulitis; they are only temporary, not curative. Negative pressure wound therapy. Laser hair removal in the gluteal fold. Phenol treatment, particularly for recurring disease.

Surgical Techniques 
With little information on which surgical approaches are better than others, several have been proposed.
 Six levels of care based on the severity or recurrence of the disease; current technical advancements are intended to hasten recovery and reduce recurrence.
- I&D, hair removal, and curtailing of granulation tissue- The removal of midline "pits" enables pit picking, or the drainage of lateral sinus tracts.
Pilonidal cystotomy: Place probe into sinus tract, remove the surrounding skin, and stitch up the wound (4)[B].
- Marsupialization: Excision of the cyst's roof and overlying skin, with skin margins stitched to the cyst floor.
- Excision: usage of flap closure; open healing is not clearly preferable to surgical closure
- Off-midline surgical excision (cleft lift or modified Karydakis procedure): A thorough analysis demonstrated that off-midline wound closure is clearly superior to midline wound closure. Off-midline closure should be the norm when closing the pilonidal sinuses surgically is the preferred choice.
A minimally invasive therapy is endoscopic pilonidal sinus treatment (EPSiT).

Serious cellulitis, excision of a sizable region, and admission

After I&D, frequent dressing changes are necessary. Additionally, follow-up wound checks are done to look for recurrence.
patient observation
Keep an eye out for fever and more severe cellulitis

Patient Education Use a washcloth to quickly wipe down the area each day.
Shave the region once a week.
Clean the crypt of any embedded hair.
Avoid sitting down for too long.

The prognosis for simple I&D is a failure rate of 55% and a healing time of 5 weeks on average.
More extensive surgical excisions necessitate lengthier hospital stays and recovery times.

Complications 
An uncommon side effect of untreated chronic pilonidal illness is malignant degeneration.

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