A pilonidal sinus is a small tunnel under the skin at the top of the buttock cleft, near the base of the spine. It usually contains hair, and it becomes infected repeatedly.
It affects young adults most often, more men than women, and it is common in people who sit for long periods, drive for a living, or have coarse body hair. It is not caused by poor hygiene, which is a persistent and unhelpful myth.
How it presents
Some people notice only a small dimple or pit in the cleft, with no symptoms at all. Those generally need no treatment.
The problems begin when it becomes infected. That causes a painful, hot, swollen lump, sometimes with fever, and it may burst and discharge pus and blood, after which the pain settles suddenly.
After that first episode, most patients settle into a pattern of intermittent discharge, discomfort while sitting, and recurring flare-ups. The area often feels wet or leaves marks on clothing.
Why it keeps coming back
Hair fragments work their way into the skin of the cleft, where friction and moisture help drive them deeper. The body responds to the buried hair as a foreign body, forming a tract that becomes chronically inflamed.
Unless that tract is dealt with and hair is kept out of the area afterwards, it recurs.
If you have an infection right now
An acute abscess needs draining rather than treating with antibiotics alone. It is a short procedure, often under local anaesthesia, and the relief is immediate.
Definitive treatment of the underlying sinus is done later, once the infection has settled. Attempting definitive surgery in the middle of an active abscess gives a worse result.
The problem with conventional surgery
The traditional operation removes a wide block of tissue containing the sinus, leaving a large wound in a location that is under constant tension, sits in a moist crease, and is difficult to keep clean. These wounds are often left open to heal from the base, which can take one to three months of daily dressings. Healing failure and recurrence are common, and time off work is substantial. This is why so many patients with a pilonidal sinus have had more than one operation.
Any treatment that avoids that wound has a real advantage, and that is the case for the laser approach.
Laser treatment
The tract is first cleared of hair and debris. A fine laser fibre is then passed along it, and energy delivered as the fibre is withdrawn destroys the lining of the tract and causes it to collapse and close.
Access is through the existing openings and one or two very small incisions. There is no wide excision and no large open wound to pack daily.
The procedure takes around thirty minutes, usually under spinal or short general anaesthesia, and is generally day care.
Recovery
Most patients return to desk work within three to seven days, compared with several weeks after wide excision.
Sitting is uncomfortable for the first few days. Expect some discharge from the small openings for a week or two as the tract closes. Dressings are simple and there is no packing.
You will be advised to keep the area clean and dry, avoid prolonged sitting initially, and begin hair removal in the area once healing allows.
Preventing recurrence
This is where most of the long-term outcome is decided, and it is the part patients most often skip.
- Keep the area free of hair. Regular removal, whether by shaving, depilatory cream or laser hair reduction, is the single most effective measure. Laser hair removal over the cleft is worth considering given how much it reduces the chance of recurrence
- Keep the area dry. Change out of sweaty clothing promptly, particularly after exercise or long drives
- Reduce prolonged sitting where possible, and break up long journeys
- Weight management where relevant, since a deeper cleft holds more moisture and friction
Risks
Recurrence, which is the main issue with pilonidal disease whatever technique is used, and is strongly linked to hair control afterwards.
Incomplete closure of the tract, occasionally requiring a repeat procedure.
Infection in the healing period.
Continued discharge for a week or two, which is usually normal healing rather than failure.
Where disease is very extensive, with multiple branching tracts, laser alone may not be sufficient and a combined or conventional approach may give a better result. You should be told if that applies to you.
Frequently asked questions
Is this caused by poor hygiene?
No. It is caused by hair working its way into the skin of the cleft, helped by friction and moisture. It affects people with entirely normal hygiene.
I have a dimple but no symptoms. Do I need treatment?
Generally not. An asymptomatic pit that has never become infected is usually left alone and watched.
How is this different from the old operation?
Conventional surgery removes a wide block of tissue and often leaves an open wound that takes one to three months of daily dressings to heal. Laser treatment works through the existing openings with no wide excision, so recovery is measured in days.
How long will I be off work?
Usually three to seven days for desk work. Sitting is uncomfortable for the first few days.
Will it come back?
It can. Pilonidal disease recurs more often than most conditions in this area, and hair control afterwards is the single biggest factor you can influence.
Should I have laser hair removal as well?
It is worth discussing. Permanent hair reduction over the area substantially reduces the chance of the sinus returning, and it addresses the actual cause rather than the result.
What should I do if it becomes hot and painful?
That suggests an abscess, which needs draining promptly rather than antibiotics alone. Get it seen the same day.
I have had this operated before and it came back. Can it still be treated?
Usually yes. Recurrent disease needs assessment of what remains and what was done previously. Bring your earlier operation notes if you have them.
Consultation
Dr. Ripudaman Singh Lubana holds a Fellowship in Minimal Invasive Proctology from IMMAST, Mumbai, and has performed over 500 laser proctology procedures including pilonidal sinus treatment.
He consults at Doctor Square Hospital on VIP Road Zirakpur, Trinity Hospital in Zirakpur, Curasia Hospital in Dhakoli, and Adesh Medical College Hospital in Mohri, Ambala Cantt.
Call 8054173528 to arrange a consultation. If you currently have a painful swelling, say so when you call so it can be seen quickly.
This page is for patient education. It is not a diagnosis or a treatment plan. An acutely painful, swollen area with fever needs same-day assessment. Every patient is examined and assessed individually, and treatment is planned around the extent of the individual sinus.
