Conservative Treatments

It is the opinion of this organization that the first treatments lean towards the conservative side.  There is still a fair amount of debate between the "non-excision" believers and the "deep and wide excision" believers.  Our belief here is that most patients have the best chance of avoiding the tragedy that some Pilonidals can become. 

We follow the results of the 600+ Pilonidal surgeries performed by Dr. John Bascom, and his finding that the term "Pilonidal Cyst" is incorrect.  Very few Pilonidals are actually cysts, almost all are simple abscesses created by infected and impacted pits in the midline of the natal cleft. To make the distinction clearer:

Cyst: A closed sac or capsule, usually filled with fluid or semisolid material.

Abscess: A local accumulation of pus anywhere in the body, formed by tissue disintegration and surrounded by an inflamed area.

Bascom has found only a couple of actual cysts in the more than 600 Pilonidal surgeries he has performed.  A true cyst, does need to be fully removed (excised).  An abscess, however, only needs to be drained and the source of the infection needs to be removed (which is the pit). Pathologists and surgeons on rare occasions find the sac is lined with epidermis, made up of cells from skin, but only cells from the outer layer of skin. That outer layer, which we call epidermis,
contains no follicles. Pathologists find epidermis lines the sac only in rare late cases where epidermis has crept into a long-standing abscess in an attempt to heal it. They never find a sac lined with intact skin and follicles, only an occasional sac lined with epidermis.

So, the bottom line (no pun intended) is WHY SURGICALLY REMOVE A HUGE CHUNK OF TISSUE THAT WOULD OTHERWISE HEAL NATURALLY ONCE THE SOURCE OF INFECTION IS REMOVED?  Most anyone who has read this site has seen numerous examples of Pilonidal excisions that have failed to heal, recurred, and generally turned the lives of some people in to a living hell. This is the reason for the "conservative" movement towards non-excision treatment. Right now, only about 1/4 of surgeons are doing conservative treatments, but their numbers are growing every day.  These techniques are not new, they have been around since the 60's.  For those skeptics among us: remember that not too long ago, lumpectomy for Breast Cancer was a "new" "conservative" technique that was widely and vehemently denounced by many surgeons.  Women began demanding better options than radical mastectomy and more surgeons learned this "new" "conservative" technique.  Now, lumpectomy is a fully accepted procedure that any woman can choose. 

The basic premise of the conservative technique is to

1) open up the abscess
2) clean it out (and is some cases, brush the tracts)
3) remove the pit
4) leave the deep tissues intact
5) let it heal

Writings on use of conservative techniques:

Bascom "Pilonidal Sinus" - published in Currant Theory in Colon & Rectal Surgery 1990 (pdf)

Lord & Millar "Pilonidal Sinus: A Simple Treatment" - British Journal of Surgery 1965 (pdf)

Bascom Pit Removal: This procedure is illustrated in a PowerPoint Presentation by Dr. Bascom, see slides 29 - 39 -- view here.

Pingree "Pilonidal Disease: A Conservative Treatment"  (pdf)

Lancing with subsequent removal of pits

Most studies quote that 85% of patients require further surgical treatment after a lancing. Excising the Pilonidal pit at the time of lancing reduces the recurrence rate to 15%. The difficulty with doing this is that the Pilonidal pit initially cannot be identified during the first drainage procedure of the abscess. Approximately 5 days later, when the swelling is reduced, the pit can be identified. Often, having the patient return 5-7 days after the lancing to identify the pit and to excise it with a small incision is possible.

Phenol Injection

What it is - Phenol is an aromatic alcohol, it exhibits weak
acidic properties and is corrosive and poisonous; it is sometimes called carbolic acid. Phenol causes wide spread tissue destruction in the injected area, including coagulation of nerves and muscle death. It is currently used very selectively for facial peels. For Pilonidal treatment it is injected into the cyst and sinuses in hopes that it will burn the tissues to the point that they no longer become infected.

Where it's done - At the doctor's office.

Recovery time - A few days.

What else you should know - Phenol Injection was at one time a promising potential cure for Pilonidal Disease. The idea was to damage the tissue to induce scarring, which would prevent further infections. Scar tissue has no pores or follicles to get infected... After further experimentation, the treatment was dropped as disease recurrences began cropping up, indicating that the underlying problem had not been solved. Most doctors won't bother with this treatment anymore.

One other note: Phenol Injection was one of the techniques used to murder prisoners at Auschwitz, the drug was injected directly into the heart and caused death in approximately two minutes.

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