New info from Bascom


Staff member
I would like to share with you all the results of my questions regarding differences between an abscess and a cyst and how we can start getting surgeons to tell the difference....

"Re: cyst and abscess, Webster's Seventh New Collegiate:
abscess n. a localized collection of pus surrounded by inflamed tissue

cyst n. a closed sac having a distinct membrane and developing
abnormally in a cavity or structure of the body

The following picture is an abscess becoming a cyst: epidermis (skin) is growing into a chronic abscess from right to left along the bottom edge of this low power view. In high power we see the growing edge of epidermis. See the diagram of Figure 11 of Bascom 1990 where a chronic abscess becomes an epithelial tube (skin lined tube).

The distinction is subtle, hard to teach and perhaps it is an
unimportant "why" as long as long as readers understand the "how" of
efficient pilonidal care. Pits are shallow. Epidermis of the follicle
less than 1cm deep covers the walls of pits in ~95% of pilonidal pit
cases. It is deeper, 1-2cm in ~4%. 2-7cm in ~1%. Epidermis can cover most of the walls of an abscess cavity, it ultimately converted the abscess into a cyst in 2-3 of my 600 cases !!! In rarest of cases the advancing epidermis becomes disordered and malignant, as the squamous cell cancer in only 1 of my 600 (highly selected. True incidence must be 1/10,000 or 100,000).

As a surgeon I can se the extent of epidermal ingrowth grossly as I
slit open the "tube" of the pit. Microscopic sections are not useful at the operating table. But I have to look closely at the specimen and I know what I seek. A lining that looks like a miniture white tube of macaroni announces an epithelial tube; an abscess is rough and

The distinction is important because a cyst must be removed, "excised", and an abscess can rmain in place. An abscess will heal following "drainage" or "cleft lift", once conditions improve. I have tried to be clear on the distinction but find some titles of my articles use sinus and some abscess.

Routine surgery should seek simplest measures to treat the commonest
abscesses and leave exceptional measures, i.e. "excision", for
exceptional cysts as they are diagnosed in the course of surgery.

An analogy to burns helps understand the futility of wide excision: A
hot burner will blister in a pattern on a hand if one lays a hand on the burner. The solution is to turn off the burner, not cut off the hand. In pilonidal disease the solution is to correct the cleft "poisons" that break down skin of the cleft, not cut away the tissue being damaged by the "poisons", and also cutting away normal tissue that surrounds the abscess using "wide excision".

When surgeons follow "...wide excision to periosteum....", which is too often given as standard instruction, they leave giant cavities or deep clefts that heal slowly or never heal. Yet the intention is good, to "remove all of the cyst wall". Except that the "cyst wall" exists only in the surgeon's mind in the vast majority of cases, planted there by textbooks and even current literature on "pilonidal CYSTS". Perhaps that explains my preference for the term, "pilonidal abscess".
See... now that makes me think I have just an abcess... I have felt the inside of (and seen with a camera)my abcess. It is just that an abcess. I have been lanced twice now so does that mean I should have a clift lift rather than a full excision???!??!? Oye vey... I wish my military doctor had this information. He is open to suggestions and I am stuck with him if I want to be treated.[:^][:^][:^][:^][:^]
And that's also made me feel a little bit better about my 'soft spongy tissue' that I discovered at the beginning of November. It sounds like skin grows down from the edges of a 'pit', and then spreads along the inside of an abcess, which turns it into a cyst. Removing the skin wall is the important bit, and perhaps I won't have regrown any skin under there.
This is interesting, but I find it odd that he cites cases of actual "cysts" occurring so infrequently. The way he describes it it sounds like an anomaly, and yet look at how many of us have it drained and then have it recur, even after multiple surgeries. I'd hate to think I have only an "abscess" and have gone through so many unnecessary and risky excisions - it seems like the only option when it just keeps on coming back. No?

And it raises a question I have - how do the surgeons figure out what's going on in there? I got the impression with my first surgery that the guy practically chose a spot at random, and the second time around it looks like they found a river running through it (and carefully followed its path). My surgeon(s) are not the bedside manner types - currently I have no insurance and rely on government aid, so the manner is of a factory shuffling its patients out like perishables. Next time I go in, I will try to ask as many questions as I can before they kick me out - on my ass, as it were.


Staff member
Moonage, if you read Bascoms other articles you will find that he puts all the blame for Pilonidals on something called "pits". In his experience, you can excise all day long and it will keep coming back until you get the pits along the midline. For many people, they have a sinus opening that clearly shows where their pit is. In others, it is hidden by the swelling in the area and only visible after a couple of weeks post surgery.
Sasha, thanks that clears things up a bit. Makes me feel a bit better since I think some pits showed up for me as well, after my last surgery. Though I can't see what's been ultimately accomplished as I'm all stitched up, one must assume they got rid of those things (the surgeon pointed them out). I'll have to read Bascom's articles, thanks for the tip.