Pilonidal Sinus treat yourself?

From home remedies to antibiotics

Pilonidal Sinus: Alternative treatment without surgery?

Prevent, treat, avoid relapse

Therapy situations and individual measures

When the hair is removed, the fistula will heal.

The Pilonidal Sinus heal itself? This is not to be expected. In fact, the cure of a Pilonidal Sinus can only be achieved with a surgical intervention. You can find out which surgical method is best for you and how minimally invasive surgery can take the fear out of the matter on our page on Pilonidal Sinus surgery

Nevertheless, conservative measures are of great importance. We tell you here which home remedies, behavioral tips, medications and non-surgical treatments are recommended.

  • in order to avoid a Pilonidal Sinus
  • abatement
  • to avoid complications
  • for follow-up treatment and wound care after an Pilonidal Sinus operation

Of course, the list does not claim to be complete. We are happy to receive your suggestions and proposals for improvement.

From home remedies to antibiotics
Pilonidal Sinus avoid

Prevent the inflammation

For minor ailments or cases of a Pilonidal Sinus in the family.

Preventive laser treatment?

If you want to prevent a Pilonidal Sinus altogether, you would have to start early. Probably the first "pits" develop already from the beginning of puberty. Our youngest patients are hardly older than 13 years.

An early, permanent removal of the hair of the gluteal fold by laser would possibly be a causal treatment. Unfortunately, it is not possible to reliably estimate which young people would benefit from laser epilation. Laser epilation is not covered by public health insurance. Several treatments are always necessary. A purely preventive laser epilation therefore seems to me to be justified only in the case of very pronounced hairiness or several family members affected by Pilonidal Sinus .

Pilonidal Sinus without treatment?

If you have few complaints or a painful inflammation has just subsided, the motivation for an operation is low. If you then read reports about difficult wound healing in the Pilonidal Sinus forum, you should rather postpone the topic.

On the one hand, this is not a problem, because the Pilonidal Sinus (almost) never becomes dangerous. That is why the guideline also advocates only observing the so-called "bland fistula".

On the other hand, surgery in the symptom-free interval is technically the easiest and minimally invasive surgery is the easiest to implement. At the latest when the next inflammatory episode occurs, you wish you had already had the treatment.

Don't be frightened. Most fistulas probably have a phase of development. Once the duct is encapsulated, the fistula does not grow too quickly. There is no fear of it spreading to the coccyx or rectum.

Early detection: The 6-point risk check

If you have to answer yes to several of these questions, you may be at increased risk. Then ask your doctor or another trusted person to look in the buttock crease for swelling, redness and especially openings.

  • Do you have a lot of body hair?
  • Has a Pilonidal Sinus occurred in close relatives?
  • Do you often sit for many hours without a break?
  • Do you often not have the opportunity to wash / shower thoroughly?
  • Are you professionally exposed to hair (hairdresser, contact with animal hair)?
  • Do you have pain when sitting?
Risk factors Pilonidal Sinus Check
Check your risk for a Pilonidal Sinus (© istockphoto.com)

Pilonidal Sinus: Optimize hygiene

General body hygiene

You don't get a Pilonidal Sinus because you don't wash enough. However, the deepest point of the buttock fold (in technical language: Rima ani) is often neglected. If hair fragments collect here, they can be massaged into the skin. Moisture and exfoliated horny scales of the skin form a breeding ground for bacteria and clog enlarged pores. So: when showering, hold one buttock to the side and rinse the rima ani thoroughly.

Prevention of inflammation

Cleaning with soap and water is helpful by reducing bacteria. In a Norwegian study, washing was even superior to disinfection with alcoholic solution.
 
A pH-neutral skin cleansing lotion (slightly acidic with a pH value of 5.5) made of synthetic detergents ("Syndet") is optimally suited. This will not attack the protective layer of the skin.
 
In case of frequent inflammations, the question arises whether antibacterial washing lotions for bacteria reduction ("decolonisation") are are better than a normal shower. Below you will find an overview of body hygiene and disinfection.
iStock 996105230
Don't forget the buttock crease when showering (© istockphoto.com)

Pilonidal Sinus: "Lifestyle"

Avoid sitting for long periods

Many problems with the buttocks are an indirect result of the upright gait. This created the deep fold of the buttocks with a constant contact surface of the buttocks, which in turn is the cause of moisture and friction.

In addition, modern people spend far too much of the day sitting. This already starts at school and continues with university, office and movement by car, train and plane.

Sitting is the new smoking?

That seems to me to be an exaggerated formulation. Nevertheless, it is certainly good for the musculoskeletal system, cardiovascular system and metabolism, and also for the sensitive area of the gluteal fold, if you do not sit for many hours at a stretch

The inevitable shift of weight from one buttock to the other and back results in a conveyor belt effect that can transport hair and impale it into the soft tissues.

Sitting is even more significant if there is already an as yet undetected Pilonidal Sinus and the small openings are functionally closed by the pressure when sitting. Then the persistent pressure load can become the trigger for painful inflammations.

Working at a high table

Sitting is the new smoking? That seems to me to be an exaggerated formulation. Nevertheless, it is certainly good for the musculoskeletal system, cardiovascular system and metabolism, and also for the sensitive area of the gluteal fold, if you do not sit for many hours at a stretch

The inevitable shift of weight from one buttock to the other and back results in a conveyor belt effect that can transport hair and impale it into the soft tissues.

Sitting is even more significant if there is already an as yet undetected Pilonidal Sinus and the small openings are functionally closed by the pressure when sitting. Then the persistent pressure load can become the trigger for painful inflammations.

Many employers have recognised that working standing up, at least some of the time, is good for the health and also the productivity of the employees and provide height-adjustable desks. Even in the home office it is not necessarily a luxury to think about such a table.

Green = recommended
SHOP Desktopia Pro white White
Height-adjustable workstation (© www.ergotopia.de)

"Coccyx Pillow"

The coccyx is by no means a useless extension of the pelvic bones. Numerous ligaments and muscles start here. Incorrect posture does not necessarily lead to Pilonidal Sinus, but to pain when sitting. Suitable seat cushions lead to a redistribution of the weight load and can alleviate such pain.

In the aftercare following Pilonidal Sinus surgery, such a cushion can make sitting easier.

haemorrhoids pillow
An orthopaedic seat cushion can bring relief

If you have a long car trip or plane ride coming up, avoid sitting for hours without taking a break. Pulling out at the rest stop more often and walking a few steps relieves the tailbone region and prevents a build-up of moisture. Even on the plane, don't sit crammed in coach the whole way to Thailand, but take a few steps down the aisle even if it's tedious.

For acute abscess

Escape emergency surgery

and thereby create optimal conditions for a gentle operation

The final exam is already in 2 weeks? The presentation for the boss is not yet ready? There are already hundreds of kilometres of motorway behind you? Your long-haul flight has just landed?

AND THEY CAN'T SIT DOWN?

These situations are typical of the acute form of Pilonidal Sinus, pilonidal abscess. The pain can become so severe overnight that you can no longer cope. Quick help is needed.

What to do with an abscess?

Severe pain is the symptom of acute Pilonidal Sinus - coccyx abscess

Pilonidal Sinus Wound not healing, bleeding, reopened?

Pilonidal Sinus OP: Optimise aftercare

These measures are essential in our view

You have already had surgery on a Pilonidal Sinus . How should you deal with the wound now? Everywhere you hear other opinions, from doctors, acquaintances and on the Internet. After all, you don't want to make a mistake. Maybe the surgery was a few weeks or even months ago and the healing progress is stagnating?

Often it is easier than you think. Remember Dr. Peter Lord: it is the hairs that cause the fistula to develop, and it is the hairs that prevent it from healing. And maybe the numerous bacteria in that region.

With our checklist wound healing we summarise what is really important. The success or failure of an operation at Pilonidal Sinus is decided in the first 4 - 6 weeks after the procedure.

Stocktaking: Was the operation performed suitable to heal the fistula?

  • Was the Pilonidal Sinus removed or merely an abscess split? In this case, a second, usually smaller operation is absolutely necessary, even if you feel symptom-free. Otherwise the risk of new abscesses is very high.
  • Has the Pilonidal Sinus been completely removed? Carefully inspect the entire gluteal fold to see if there are still any conspicuous openings. In this case, the recurrence is pre-programmed.

These points must be observed

  • Hair removal of an approx. 2 cm wide fringe around the entire wound (shaving, possibly depilatory cream, possibly wax strips, plucking). The most important area is a zone about 3 cm below the deepest point of the wound. You can only look there if you spread your buttocks a little.
  • Showerat least once a day

You should omit these measures

  • Antibiotics are useful for a short time once complete suture closure of the wound has occurred. One starts with the first dose at the induction of anaesthesia as an infusion or as a tablet on the morning of the operation. Continuing this treatment is controversial among experts. It is probably not advisable to give antibiotics for longer than 3 days to prevent wound infection.
  • Tamponades are painful and ineffective. The wound after removal of the fistula is actually a (relatively) clean wound and does not need to be prevented from closing. This is different from when an abscess has only been opened and the drainage of pus is to be secured for a few more days.
  • Treatment of "wild flesh" with silver nitrate pen: These so-called hypergranulations are always a sign of an obstacle to healing, mostly from penetrated hairs. Doctoring around with the secondary growths is of no use at all.

Everything done right and the wound still does not heal?

This is plan B: Sometimes a wound does not heal despite inconspicuous ultrasound findings and optimal care. If no healing progress is seen for one to two months, the truth must be faced. A new operation is due, the options are a new wound cleaning or the Karydakis plastic.

Our rating

The list of possible measures

What really helps

Washing and disinfecting

Hurt? First disinfect the wound, we learn from an early age. After all, inflammations are caused by pathogens, which must be eliminated with disinfectants. Less well known is the fact that almost all disinfectants and antiseptics not only kill the bacteria but also damage the normal skin flora* as well as the cells of the body's own defence (leukocytes) and wound healing (fibroblasts).

Without a wound or with normal wound healing there is therefore no good reason for disinfection. Colonisation, i.e. colonisation, with bacteria is in any case unavoidable in the region of the gluteal fold and the anus and is also not harmful. Only in the case of infection, i.e. pathogenic bacterial growth in the wound, can antiseptics be useful in justified individual cases.

* Today, the skin flora is better called the microbiome . Flora, after the Roman goddess of flowers and youth, refers to the plant kingdom, to which bacteria do not belong.

Disinfection and antiseptics for Pilonidal Sinus
Bacteria in the Petri dish - Should you disinfect at Pilonidal Sinus ? © istockphoto.com

Cleaning and disinfection products at a glance

"Thoroughly rinse the wound daily (several times)". - This is the most commonly reported recommendation for wound care. What does science say?

A 2012 Cochrane analysis found different types of wound irrigation (tap water vs boiled water vs saline vs no irrigation) were equivalent.

The Robert Koch Institute (RKI) nevertheless comments as follows: "Every rinsing fluid must be sterile. Tap water is not free of microorganisms. Only sterile solutions may be used to rinse wounds."

What the RKI says is the law. 

Nevertheless, I feel I can comment on these opinions:

  • Irrigation of the wound in the actual sense is rarely necessary after Pilonidal Sinus surgery. Wounds left open almost never become infected. In the case of a sutured wound, irrigation is not sufficient in the event of infection. The wound must usually be opened surgically.
  • The recommendation refers to wound care in homes, i.e. of problem wounds in elderly and/or sick patients. The patient with Pilonidal Sinus is usually young and healthy.
  • The gluteal fold never becomes permanently sterile. Neither are the patient's underpants. When it comes to the pragmatic question of whether showering, i.e. general body hygiene, is permitted after surgery, I don't think you have to be more pontifical than the Pope.
Tap water for rinsing during wound care after Pilonidal Sinus OOP?
Is tap water suitable for wound irrigation? RKI and DGKH advise against it!

Improve water quality: The German Society for Hospital Hygiene (DGKH) says on the subject of tap water: "When using terminal sterile filters at the water outlet, drinking water ... can achieve the necessary microbiological purity. However, these filters should be changed daily...". 

Suitable filters are available as disposable products or in rental systems with included reprocessing. The best solution is a terminal system as a handpiece at the shower. This seems to me to be a recommendable and practicable solution

It is not necessary to "clean" the wound. However, once or twice a day we would recommend showering off secretion residues, loose hairs and exfoliated horny scales of the skin in the fold of the buttocks.

Bacteria filter for showering out wound after Pilonidal Sinus OP
Germlyser D, medical shower filter (Image © Aqua free GmbH)
Sterile filter for post-treatment for Pilonidal Sinus
With a suitable filter shower head, wound rinsing is easy (Image © Aqua free GmbH)

Conclusion: Showering the buttock crease and wound with filtered tap water is recommended all round.

New in wound treatment are stabilized aqueous preparations of NaOCl/HOCl. They combine very good efficacy against almost all types of pathogens including resistant problem germs with very good tolerability. It is the only antiseptic permitted in the treatment of severe infections in the abdominal cavity. and central nervous system. NaOCl/HOCl is therefore already referred to as the new gold standard in wound treatment.

Representatives of this group are, for example, the products Veriforte™ med, Granudacyn®, Lavanox-Serag® and Microdacyn®, which are available as wound gel, irrigation solution and wound spray.

Pros:

  • No rinsing required
  • No known resistances
  • Non-toxic to somatic cells
  • Treatment not limited in time
  • Application in body cavities possible
Optimal antiseptic for wound treatment after Pilonidal Sinus surgery
NaOCl-HOCl causes single-cell microorganisms to burst, but does not damage body cells! (© Focusmed Beyer KG Austria)

Conclusion: NaOCl/HOCl can be recommended without reservation as an effective and gentle antiseptic.

A block of curd soap used to belong in every household. And many can still remember that our grandmothers praised a bath in hot soapy water as a panacea for inflammation.

Soap is chemically the sodium salt of fatty acids. Some brand names (Palmolive®) are reminiscent of the fats used, palm and olive oil. In curd soap, the soap core is separated by adding common salt to form a soap solution.

Curd soap is alkaline and has a good cleansing effect. However, this pH value attacks the acid mantle of the skin. The advantage of curd soap is that it is free of fragrances and dyes and may therefore cause fewer allergies.

Therapeutic efficacy not proven: A search of the PubMed medical database revealed no evidence that curd soap has a healing effect.

Only sporadic, unproven recommendations can be found. In the prevention of wound infections after injury proved saline superior to washing with soap.

Conclusion: The nostalgic curd soap bath cannot be recommended on a scientific basis.

Red = not recommended or not available
Curd soap as a home remedy at Pilonidal Sinus cannot be recommended.
Curd soap as a home remedy at Pilonidal Sinus?

Octenidine (Octenisept) is effective against bacteria, fungi and to a limited extent against viruses. It is well tolerated and does not burn on the wound. It has no adverse effects on wound healing. Due to its slightly viscous consistency, it is well suited as a lubricant for shaving. 

Precautions for use:

  • In the case of wound irrigation, the preparation must not be introduced or injected into the tissue under pressure.

  • It should not be used simultaneously with PVP-iodine based antiseptics on adjacent skin areas.
Chlorhexidine for antibacterial washing in the case of Pilonidal Sinus
Chemical formula of chlorhexidine (Yikrazuul - Own work, Public domain, https://commons.wikimedia.org/w/index.php?curid=4347057

In Germany,chlorhexidine is mainly used in dentistry as a solution for mouth rinsing. A further, recognized application in England and the USA is the use before operations to reduce wound infections.

It has a broad spectrum of activity against gram-positive and gram-negative bacteria and yeasts. Allergic reactions and an influence on connective tissue and skin cells have been described.

I would consider the so-called decolonisation to be suitable for preventing inflammations in connection with risk situations (travel, exam preparation, etc.) at Pilonidal Sinus . Due to the approval status, the treatment would have to be classified as an off-label therapy. In case of a permanent treatment, negative effects would probably predominate.

There is currently no guideline recommendation on chlorhexidine.

Chlorhexidine wash lotion is available in Germany only to healthcare professionals as Skinsan Scrub N™. Via European distributors Desinclor Chlorhexidine Antiseptic Soap 0.8% offered. In the USA, preparations containing chlorhexidine are available without prescription. In an Australian study, decolonisation by washing with chlorhexidine was significantly more effective in preventing wound healing problems than taking antibiotics in tablet form.

As an ingredient of Bepanthen Antiseptic Wound Cream, chlorhexidine is approved for the treatment of superficial wounds. In individual cases, its use may be justified in the case of wound healing disorders that cannot be influenced in any other way.

Wound irrigation with chlorhexidine probably impedes healing more than it helps and is not recommended.

Conclusion Chlorhexidine: suitable for skin antisepsis before operations, for decolonization in case of MRSA colonization. Occasion-related application for the inflammation prophylaxis of coccygeal fistulas, e.g. before long journeys, seems justified. For antiseptic wound treatment chlorhexidine is suitable with restrictions, first choice are HOCl, polyhexanide and Octenisept.

PVP - iodine solution is suitable for preoperative skin and mucous membrane disinfection. Iodine is recommended to a limited extent for wound irrigation. The brown colour contaminates the laundry. In the case of slightly contaminated wounds, the negative effects on wound healing predominate. 

Creams, powders, ointments

Has a herb already grown against the Pilonidal Sinus? Germans spend almost €5 billion a year on over-the-counter medicines. 65 million packages of ointments and creams cross the pharmacy counter every year.

We have tried to clarify what you can save and which preparations have a proven benefit.

The disinfecting effect of iodine on bacteria, viruses, fungi and spores has been known for a long time. Due to its universal effectiveness without known resistances it is often used in many medical fields (Review of iodine in wound treatment).

Elemental iodine is not water soluble and is toxic to tissue. Povidone iodine (syn. PVP iodine, polyvinylpyrrolidone-iodine), on the other hand, is water-soluble and tissue-tolerant and continuously releases small amounts of iodine. The substance is available as tincture and ointment. 

Iodine should no longer be considered an old-fashioned antiseptic.... Perhaps its greatest strength is that bacteria have not found a way to develop resistance even after 150 years of use in humans.

We have had good experience with PVP iodine ointment to support delayed wound healing in the gluteal fold area. The positive effects seem to outweigh the experimentally found inhibition of connective tissue cells (fibroblasts) and cells of the immune system. Numerous clinical studies prove that iodine-containing antiseptics have a positive effect on the healing rate and healing time of chronic wounds.

Caution is advisable in the case of large wound areas through which large quantities of iodine could enter the organism, as well as in patients with previous heart, kidney or thyroid diseases. Allergies can also occur occasionally, very rarely reaching anaphylactic shock(1)(2).

Conclusion: Not every wound should be disinfected with iodine. We use PVP iodine for complex mixed colonisation of delayed healing, strong smelling or exuding wounds.

Yellow = suitable under certain circumstances

These preparations are registered as traditional medicinal products without registration studies solely on the basis of many years of use for the area of application. They are intended to promote the "maturation" and spontaneous opening of encapsulated centres of pus (abscesses). Since most abscesses burst at some point if you wait long enough, the benefit of these preparations does not seem to be proven.

  • ilon® Ointment classic (successor product to ilon® Abscess Ointment): Ingredients are larch turpentine (Terebinthina veneta), turpentine oil of the beach pine type eucalyptus oil, white vaseline, yellow wax, stearic acid, oleic acid, polysorbate 20, rosemary oil, thyme oil, thymol, chlorophyll-copper complex (E141), butylhydroxytoluene (E321). My literature - research on "turpentine" and "abscess" only revealed the reference to the use since 2000 years, the causation of abscesses by turpentine injection in experimental animals and studies on contact allergies caused by turpentine. 
  • Ichtholan 50% ® Ointment contains the active ingredient ammonium bituminosulfonate (ichthyol), yellow vaseline, microcrystalline hydrocarbons (C40-C60), wool wax and purified water. Ichthyol belongs to the group of sulfonated shale oils and has been used since the 19th century as an anti-inflammatory and antibacterial agent in dermatology, in higher concentrations of 20 - 50 % also for abscesses. The medical database PubMed does not find a single study on the treatment of abscesses for this active substance either.

Cortisone - preparations

Contribution in progress

Metronidazole has been known since 1959 as an antibiotic effective against anaerobic bacteria and protozoa. From the application in dermatology for rosacea and perioral dermatitis it is known that besides the antibacterial effect also a non-specific anti-inflammatory effect is given. Furthermore, metronidazole stimulates the growth of keratinocytes, the cells of the skin. In gynecology, metronidazole is frequently used as vaginal suppositories.

In proctology, a 10-percent metronidazole ointment has been successfully applied for pain reduction and reduction of the secretion volume in anal fistulas in Crohn's disease as well as for pain reduction after hemorrhoid surgery. The tolerability is good, allergies and discomfort during application are rare.

A pilot study on the treatment of non-healing wounds after sinus pilonidal surgery was published in 2016. It showed a healing rate of 80 % for wounds that had previously not healed for an average of 16 weeks. Based on these very encouraging results, a long-term study has been running since 2019, with results expected in 2023.

If after the operation of a Pilonidal Sinus the wound does not heal despite exhaustion of all surgical possibilities and optimal wound care, there are few therapeutic alternatives. Therefore, most experts consider the use of this 10% metronidazole ointment justified. From the British company SLA Pharma, the preparation Ortem™ is sent on request under certain conditions, but according to my information so far only in Great Britain.

In Germany, it is basically possible to have a comparable ointment prepared as a prescription by a pharmacist. Due to the lack of approval for this indication, this type of treatment must be classified as an "off label" therapy, i.e. there is no product liability of a pharmaceutical company.

Metronidazole Vaseline 10% 50 g

Metronidazole, micronized 5.0 g
Miglyol® 812 6.0 g
Vaselinum album 39.0 g

We have had good experience with this so far, the healing rate of problematic wounds after Pilonidal Sinus surgery is in the order of 60-80%. The responsibility for such a prescription basically lies with the prescribing doctor, we cannot assume any liability whatsoever for effectiveness and side effects.

Yellow = suitable under certain circumstances

Conclusion: 10% metronidazole as a topical preparation can be used when a wound fails to heal despite exhaustion of established options.

Honey was used as an ointment for wounds by the Sumerians and Egyptians in ancient times. Scientific studies have shown that honey

  • favours the cleaning of wounds
  • due to its acidic pH value of 3.2 - 4.5, it improvesthe release of oxygen in the tissue
  • Mediators of inflammation reduced
  • promotes healing and tissue regeneration and
  • has anantibacterial effecteven against problem germs such as methicillin-resistant staphylococci and pseudomonas(Curtis).
Manuka honey for wound care
Honey jar with Manuka flowers from New Zealand (Leptospermum scoparium. Photo: istockphoto.com)

The active ingredient in Manuka honey from the flowers of the Manuka bush is not hydrogen peroxide as in other honeys, but the more tissue-tolerant methylglyoxal (MGO). The antimicrobial effect is given in UMF® (Unique antimicrobial Manuka Factor), for medical use honey with a UMF > 10 is recommended. However, the effect also seems to depend on other factors such as the storage time, as a study with different UMF qualities showed.

Medicinal honey is filtered and gamma sterilized. This kills bacteria and spores while maintaining biological activity. Edible honey is usually heated and loses much of its beneficial activity.

Preparations of medicinal Manuka Honey are available in tubes (e.g. MediHoney®), in combination with alginate(Algivon Plus®) or gauze(Actilite®).

The benefits of honey in wound treatment appear to be greatest in the early stages of wound cleansing. According to a Cochrane analysis, infected post-operative wounds treated with Manuka honey heal faster than those treated with antiseptics and gauze, which makes the treatment of wound healing disorders after conventional radical surgery, for example, appear to be a sensible area of application. However, the DGfW was unable to come up with a recommendation in its S-3 guideline, which was adopted in 2014, as the existing studies have so far failed to demonstrate any definite benefit, but have shown an increase in pain.

Yellow = suitable under certain circumstances

Based on the literature, medicinal honey seems to be an option when a sutured wound has burst open again or an open wound does not want to heal. We do not have our own experience with honey so far.

Shaving, epilating, waxing, laser?

Hair Removal

Prevention, post-operative treatment and recurrence prophylaxis

Where do the hairs come from that you find in the cave of a Pilonidal Sinus ? 

  • The hair mainly comes from hair roots in the area of the gluteal fold
  • New studies show that hair from the head can also be found in the fistula ducts, hair from the back only rarely. Short, freshly cut hair from the neck seems to penetrate the skin most easily.
  • Furthermore, it happens that deposits of keratin dandruff due to a disturbed hair formation lead to an expansion of the hair root. 

In my experience, a hair-free buttock crease reduces the risk of healing problems after surgery. Many supposed recurrences are actually poorly healed surgical scars(type IV fistulas) that probably could have been avoided by consistent hair removal in the early phase after surgery. Penetration of loose hairs from other parts of the body is most likely to be achieved by covering them with a closed dressing.

Depilation and epilation

Procedures that only remove the visible part of the hair, the hair shaft (shaving, depilatory cream) are called depilation. They last for about 2 weeks and by their very nature cannot affect the hair root in depth and thus the risk of a real recurrence. Contrary to popular belief, depilation does not change the growth rate. 

With real epilation, the hair bulb is also removed and thus an effect is achieved for about 6-8 weeks. This includes plucking, waxing, sugaring and in a broader sense also laser epilation and electrolysis.

Shaving - Useful, indifferent or harmful?

The 2016 WHO recommendation says: "Shaving is strongly discouraged at all times, whether preoperatively or in the operating room." - In a healthy person, we see it the same way: there is no medical reason to shave in any part of the body.

However, we consider shaving to be indispensable before the operation Pilonidal Sinus, and preferably already during the planning stage. Why? Especially in densely haired patients, the true extent of the Pilonidal Sinus and the number and localisation of the pits can only be assessed in the shaved state. We use conventional razors for this. This allows us to shave directly on the wound, even in the depth of the buttock crease and in combination with Octenisept as a disinfectant, without spreading cut hair fragments over the wound.

For laser epilation, which is almost always the first step of the operation, the hair must be cut exactly at skin level so that there is no superficial burning of the skin.

In other operations and in other regions of the body, the 

Everything for an optimal post-operative treatment after Pilonidal Sinus OP
Alcohol-free antiseptic, hospital shavers and bikini line shavers

After the operation of a Pilonidal Sinus we also consider the shaving of the surroundings of the wound as essential. 90% of all problems are caused by mechanical irritation of the wound by the surrounding hair.

We therefore recommend shaving until the wound is closed and the scar is stable. In the early phase of wound healing, the scar tissue is still soft and vulnerable, so that hairs can reattach. 

The easiest way to shave is with simple disposable razors ("hospital razors", e.g. from Wilkinson®) after spraying with an alcohol-free antiseptic (e.g. Octenisept®). The viscous consistency of this agent ensures that the razor glides effortlessly over the skin and the shaved stubble does not fall into the wound. The antiseptic effect prevents skin irritation. In hard-to-reach areas, a bikinizone razor can be helpful. The use of clippers or beard trimmers should also work. I have received positive feedback from patients especially about precision trimmers such as those from Braun or Beurer.

Tips for a successful shave can be found in our video:

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With conventional epilation, the hair is pulled out with a rotating tweezer system (e.g. Braun Silk-épil, Philips SatinPerfect). This effect can also be achieved with heated wax strips or a lightly caramelised paste of sugar, water and lemon juice (sugaring ). The latter is considered a particularly natural and gentle method.

Pulling on the hair causes the hair to break off just above the hair root, the root and growth zone are not removed. Although there will be no hair on the outside for a few weeks, the hair will grow back again and again.

This epilation technique is mainly suitable for cosmetic hair removal. It seems unlikely to me that it can prevent the formation of a Pilonidal Sinus . In contrast, for post-operative treatment after radical surgery, depilation may also be a means of preventing the hair from growing from the side into the still open surgical wound.

Epilation
Mechanical depilation © istockphoto.com

Chemical hair removal

Depilation with depilatory cream is a widely used and painless option for temporary hair removal that produces less unpleasant stubble than shaving. It is based on the splitting of disulphide bridges in and on the hair by thioglycolates. The hair shafts are thus loosened to about 1 - 2 mm under the skin. Sharp stubble as with shaving is avoided.

The commercially available preparations differ essentially in the concentration of active ingredients and carrier substance, care substances as well as fragrances and preservatives. In the area of the buttock fold, one would resort to products explicitly approved for the intimate area.

The cream is applied and left for about 10-15 minutes until it is washed off again or scraped off with a scraper. During this process, the hairs fall out. It is advisable to test a preparation on a less sensitive area before treating sensitive areas such as the buttock crease.

This avoids skin irritation, which in extreme cases can lead to sores such as burns or abrasions. The use of hair removal cream should not be combined with waxing or mechanical epilation, as these methods make the skin more sensitive.

Laser Hair Removal

Even the best surgical technique cannot guarantee a 100% success rate. If a fistula occurs again after an operation, either new "pits" have formed or hairs have drilled into the less stable scar tissue. This problem can be prevented if the hair roots in the critical area are permanently inactivated by light energy. A recent study showed a halving of the recurrence rate after surgery from 19.7% to 9.3% after laser hair removal.

Electric hair removal (electro-epilation, electrolysis)

  • In needle epilation, a fine wire is inserted into the hair follicle parallel to the hair shaft and the hair root at the bottom of the follicle is destroyed with an electric current. The loosened hair is plucked out with tweezers.
  • In medical electrolysis treatment, the hair root is sclerosed by a short-wave pulse, which is also applied via an inserted probe.

These methods are considered by the American FDA to be the only technique of truly permanent hair removal. The risks include infection of the hair follicle. As with laser epilation, repeated treatments must be performed.

This treatment requires profound training and experience and is not available nationwide. In addition, there are - quite rightly - no therapists who work for the fee of € 6.45 offered by the statutory health insurance via EBM number 10340 (epilation by electrocoagulation).

On the website of the professional association you can check if a therapist in your region offers this technique. It has advantages especially for very light and/or delicate hair that does not respond optimally to laser treatment.

Conclusion: Effective method for hair reduction, depending on availability, self-payment.

Green = recommended
Should one swallow medication?

Antibiotics

Systemic antibiotics (tablets, infusions)

Antibiotics are not treatment of first choice. They can help to contain an acute inflammation and thus save time. In the case of acute symptoms, e.g. on holiday, such treatment can sometimes bridge the time until the patient is able to return home. However, the success of antibiotic treatment is a matter of luck:

There is always a mixed spectrum of different bacteria, so that broad-spectrum antibiotics are necessary (e.g. cefuroxime, amoxicillin/clavulanic acid). However, it is quite possible that the bacteria causing the inflammation are resistant to the antibiotic used or that the antibiotic does not reach a sufficient effective level at the site of inflammation. A healing of the fistula can never be achieved with antibiotics. 

Yellow = suitable under certain circumstances
Antibiotics for Pilonidal Sinus
Antibiotics for Pilonidal Sinus
Other countries, other customs

Treatment methods from all over the world

Away from western orthodox medicine

The method was first described by Lawrence and Greenwood in 1964. They state a cure in 84% of cases. 

Girgin reports a success rate of 64.5% for single and 95% for repeated introduction of crystalline phenol into the fistula tract. The treatment is carried out under local anaesthesia, the hair is removed from the fistula tract with a clamp and the tract is rinsed. The surrounding area is kept hair-free during the entire healing period.

According to German drug law, phenol may no longer be used (negative monograph Pharm. Ztg. 143 (1997), 4103 and 4386). It is toxic and irritates skin and mucous membranes.

The accompanying measures correspond to a restrained pit picking. An additional benefit of the phenol therefore does not seem to me to be proven.

phenol2.svg
Chemical formula of phenol © By NEUROtiker
Studies on phenol instillation
Author
Year
Quantity
% Follow up
Years Follow up
% Recurrence
% Complication
Maurice
1964
21
Not specified
1,5
19
Not specified
Aygen
2010
36
100
4,5
13,9
8,3
Girl
2012
48
96
1,83
5,0
Not specified
Calikoglu
2017
70
95,9
3,3
14,3
8,6
Dogru
2020
1026
Not specified
Not specified
15,7
Not specified

Vaseline, henna and tetracycline - the mixture from Iraq

(not available in Germany)

A randomized study on 400 patients was published by the University of Sulaymani in Kurdistan. In the therapy group a mixture of 100 g vaseline, 50 g henna powder (Lawsonia inermis) and 5 g tetracycline was injected into the fistula tract. In the control group the fistula was excised with primary wound closure. Healing rates were 94 % for surgery and 89 % for ointment injection. Unfortunately, I did not find any information in the work on the follow-up rate and the observation period. Conclusion: Unconventional idea, assessment not possible.

Traditionally, Ayurvedic medicine uses thread drains impregnated with plant extracts and salts to treat fistulas. A publication can be found on a Combination of surgical excision, sclerotherapy with hot oil and application of copper sulphate. The scientific findings on these methods allow only anecdotal mention, but no evaluation of the procedure.

Our recommendation traffic light

Green = recommended
Yellow = suitable under certain circumstances
Red = not recommended or not available

In no case should the following presentation serve as a guide for uncritical self-treatment. The recommendations follow to the best of our knowledge from our own experience and selected publications. They do not represent a systematic analysis of available studies. In any case, consult a specialist experienced in wound treatment before use.