Avoid coccyx fistula
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The 6-point risk check
Answering the following questions can help you to identify an increased risk of Pilonidal Sinus . If you answer 'yes' to several of these questions, we recommend that you ask your doctor or another trusted person to examine the gluteal fold for signs such as swelling, redness and especially small openings.
- Do you have a lot of body hair?
- Have any close relatives experienced Pilonidal Sinus ?
- Do you often sit for long hours without a break?
- Do you rarely have the opportunity to wash or shower thoroughly?
- Are you professionally exposed to hair, for example as a hairdresser or in contact with animal hair?
- Do you have pain when sitting?
Feelings of shame should not prevent you from seeking professional medical help if you suspect Pilonidal Sinus . Your health deserves it. The chances of a simple solution to the problem are highest in the early stages.
Sedentary life: Health risks of office and school desk
It may sound dramatic, but it is actually unhealthy to sit for hours without a break. This habit not only causes back pain, but also affects your overall health. An analysis of 27 large studies from 2018 found an increased risk of cardiovascular disease, diabetes and even tumors of the intestines and abdomen, as well as an overall shortened life expectancy, the longer you sit every day.
And of course, the sensitive area of the gluteal fold also suffers from prolonged sitting. The unavoidable, constant shifting of weight when sitting can act like a conveyor belt in the buttock crease, transporting unwanted hair to unwanted places - a potentially painful scenario.
Sitting is even more important if an undetected Pilonidal Sinus already exists. The pressure when sitting can functionally close the small fistula openings (pits), which can lead to painful inflammation.
Wondering what you can do?
- Use a height-adjustable desk at your workplace so that you can work standing up from time to time and do something good for your body.
- Allow yourself regular short breaks to move around and stand up.
- When traveling: Drive out of the rest stop more often and walk a few steps, and don't sit crammed into coach class on the plane all the way to Thailand!
- Make your calls standing up to activate your muscles and improve your posture.
- Use the commercial breaks while watching TV to get up, stretch and move around a bit.
- Bring sporting activities back into your everyday life and feel the energy that movement brings into your life.
- Let apps for smartphones and smartwatches motivate you to move more and get your body moving.
Many employers have recognized that working standing up at least some of the time is beneficial to employees' health and therefore provide height-adjustable desks. It also makes sense to think about purchasing such a desk for home offices. Another positive effect is that there is evidence that people work more creatively and purposefully when they don't spend the whole day sitting down.
Tips for personal hygiene with pilonidal sinus
General body hygiene
You don't normally get a Pilonidal Sinus because you don't wash yourself enough. However, the deepest point of the gluteal fold (in technical terms: 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
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 .
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
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.
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.
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).
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.
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.
Antibiotics
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.
Treatment methods from all over the world
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.
Studies on phenol instillation
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
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.
Publications on lifestyle, lasers, wound care
Biddle, S., Bennie, J., Bauman, A., Chau, J., Dunstan, D., Owen, N., Stamatakis, E., & van Uffelen, J. (2016). Too much sitting and all-cause mortality: is there a causal link?. BMC Public Health, 16(1), 1-10.
Dunstan, D. (2010). Too Much Sitting The Population Health Science of Sedentary Behavior. Exercise and Sport Sciences Reviews, 38(3), 105-113.
Eanes, L. (2018). CE: Too Much Sitting: A Newly Recognized Health Risk. AJN: American Journal of Nursing, 118(9), 26-34.
Kennedy, M. (2018). Sitting Our Lives Away. AJN The American Journal of Nursing, 118(9)
Pronk, N. (2011). The Problem With Too Much Sitting A Workplace Conundrum. ACSM's Health & Fitness Journal, 15(1), 41-43-41&ndash-ndash;43-41-43.
Wallace, J. (2015). Effect of Prolonged Sitting and Breaks in Sitting Time on Endothelial Function. Medicine & Science in Sports & Exercise, 47(4), 843-849-843&ndash-ndash;849-843-849.
DR. BERNHARD HOFER & FLORIAN LIEBL
Specialists in Visceral Surgery and Proctology - PartG mbB
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