What is wrong with so much pilonidal care?

What is wrong with so much pilonidal care:

This is a critique of the care that Daniel received in the previous blog: “A story that demonstrates how much of our medical community fails in properly treating pilonidal disease”.

Daniel was first treated with antibiotics for his pilonidal disease (also called a pilonidal cyst or pilonidal abscess).  Antibiotics may quell a small pilonidal abscess but often aren’t effective as they can’t reach the center of an abscess (a pocket of infection).  The best treatment for a pilonidal infection is surgical drainage (which can be performed in a surgeon’s office).  Antibiotics are only required if there is cellulitis (a swollen, red and often tender infection of the skin and surrounding tissue).

The emergency room doctor who first evaluated Daniel and drained his abscess was clearly uncomfortable treating pilonidal disease as are many doctors.  Poorly performed drainage procedures are uncomfortable, traumatizing, and frighten patients from receiving timely care in the future.  If you have a pilonidal abscess, you are best to go to a surgeon to have it drained.  Most surgeons will squeeze patients into their practice schedule for this simple and quick (in the proper hands) procedure.

Wound packing is “old fashioned” and painful for the patient and caregiver.  Abscesses are properly drained with an oval-shaped incision so that the skin edges don’t seal quickly, and the abscess can fully drain on its own through this opening.  Packing of such wounds is not needed and actually prevents the infection from draining (like a cork) rather than wicking the infection from under the skin surface.  Soaking in a warm bath is encouraged to draw the infection out.  A gauze pad is recommended to cover the drainage hole to avoid soiling sheets and clothing and should be changed frequently to keep clean.

It was appropriate for Daniel’s surgeon to advise and perform surgery after 3 bad pilonidal infections in a short period of time.  The choice of a wide excision with midline closure, however, was a poor operative choice.  Firstly, there is no such thing as a “pilonidal cyst”, so removing a large amount of tissue in a deep cleft to remove the entire “cyst” is unnecessary.  All that discarded tissue is normal and will heal and recover given the proper conditions as there is NO CYST.  Secondly, closing the wound in the middle of a deep cleft over dead space (the empty space left after removing the so called “cyst”) leads to the accumulation of infected fluid and a recurrent wound, often worse than the original pilonidal problem.  Furthermore, wounds in a deep, moist, airless cleft don’t heal well.

Because the basic problem that leads to pilonidal disease is a very deep cleft or valley between the buttocks that traps hairs or debris, any procedure that does not ‘shallow the cleft’ will not fix the problem. Therefore, Daniel was left with an open wound, likely worse than the original pilonidal wound in a deep cleft since the operation he had did nothing to make the cleft shallower.  Referral to a wound clinic was just passing the buck.  The wound clinic doctors didn’t stand a chance at healing Daniel’s wound.  But the wound clinic doctors are not exonerated, as they should have known better than subjecting Daniel and his parents to months and months of visits, expense, and futility (especially the HBO therapy).

Unfortunately, Daniel’s story is not uncommon.  At The Sternberg Clinic, I see many young patients with similar stories.  Please do your research.  Find the right doctor with experience with the Cleft Lift Procedure.  There are only a handful of us.  Travel for your surgery if necessary.  It’s worth it.  See what some patients have written.

Jeffrey A. Sternberg, MD, FACS, FASCRS Pilonidal Surgery, Board-Certified Colorectal and General Surgeon located in Civic Center, Hayes Valley, San Francisco, CA

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