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Melanie Cole, MS (Host): Pilonidal cysts can be so painful. If you’ve ever met someone that has one, they might tell you that it feels as if you're pressing your tailbone up against the sharp corner of a table all the time. My guest today to tell us about these is Dr. Reza Kermani. He’s a trauma, critical care, and general surgeon, and a member of the medical staff at Palmdale Regional Medical Center. Dr. Kermani, what is a pilonidal cyst?

Reza Kermani MD, FACS (Guest): Well hi, and thanks for having me to talk to you guys today. The pilonidal cyst is basically a small cyst that we’re usually born with. They are part of the remnants of the mesothelial cells that develop into who we are as people and embryos. In some patients, these cysts kind of trap themselves right in between the folds of the buttock in the space called the intergluteal cleft. It’s basically the little space in between your two butt cheeks, higher up than your anus. These are small little congenital cysts that just sit there and lie there above your sacral bone in the subcutaneous or fatty tissue under the skin.

What happens is they're in a location where there’s a lot of pressure exerted on them every time you sit, move around, or exercise. As a result, these cysts can very easily become irritated with movement and the hair in that area. When they become irritated, they usually get swollen, they secrete fluid, and can oftentimes even become affected.

Host: Is this something that parents would notice in their little child? Or because there’s a lot of fat pads in children, we don't see them until they're adults. When do you usually notice these?

Dr. Kermani: So, we tend to notice them anywhere from eight years old up to even adults get it in their 30s. The majority of patient’s I've been seeing tend to be either teens in their late teens or early young adulthood. Any child can have it and you can have it at any age, but typically it happens after the patient’s been sitting up, moving around, and has had time to kind of irritate that area. So, we don’t often see it like in infants and toddlers. But in any child, even as young as eight years old, if you notice a little lump or something that looks like a zit or a pimple in the space in between the two butt cheeks, that typically is a tip off that the patient probably has pilonidal cyst disease.

In some patients, we don’t see it until they are a bit older because their cysts are a bit deeper and it takes more hair getting down there to irritate it. So, in those patients, we see them after they grow hair in that area. That, again, tends to be young adulthood in their early to mid-20s is when we notice them. But, again, you can see it in kids as young as six or seven and people as old as in their 30s.

Host: If someone does notice one or it starts to hurt, what kind of doctor do they go see? Do you always have to see somebody about them? Or do some people just go about their lives and don’t really do anything about them?

Dr. Kermani: Now you could try to ignore it and see if it goes away. Sometimes it does. It depends on how inflamed or irritated the area gets. Most of the time patients end up going to either their primary care doctor, an urgent care center, or an emergency room. Typically, whoever the provider is staffing that area will treat it by lancing the pilonidal cyst. What they do is they basically open, with a knife, open up the cavity of the cyst and they drain any fluid that’s in it. They have the patient carry out local wound care until the cyst heals. The problem with this is that although this may take care of any immediate discomfort or any immediate infection by opening up the cyst and any bacteria that may be in it. Until the cyst is completely removed, the diseased tissue remains in place and it’s going to reoccur. It’s just a matter of when.

It’s not a good idea to ignore these. It’s typically better to keep an eye on it. Sometimes something as simple as anti-biotics will be enough to calm down the irritation and the infection in the area and the cyst will go away. The recommendation is that if these cysts keep coming back and keep bothering you, you're better off getting them removed so as not to have to deal with them on a repeated basis.

Host: Doctor, is there anything you can do—before we talk about what that treatment looks like—is there anything you can do at home to ease the pain or the swelling? Do you recommend weight loss or exercise or even certain vitamins?

Dr. Kermani: Well weight loss does seem to help. In terms of vitamins, there’s no commonly accepted consensus on anything that would help. There are a lot of people out there saying homeopathic remedies like celery smoothies everyday and a plant diet can help. I haven’t seen any of that bear out in clinical practice. The one thing that does seem to help though is if you happen to have a very hairy backside, shaving in that area or doing laser hair removal in that area or waxing to remove hair in the area does seem to help. Because one thing we do repeatedly see if small little tiny hair fibers creep into those little areas where the cysts are located. When the hair lodges there, every time you move around the hair scrapes up against the cyst and causes irritation. So, keeping the area nice, clean, dry, and free of hair does seem to help. Then some patients who have pilonidal disease… Once we just practice good hygiene there and shaving there, that may be enough to cure it without them having to undergo any other treatment.

Host: What are those other treatments? What do they look like?

Dr. Kermani: Well, so the initial treatment for the acute or the sudden infection or inflammation is to basically have it lanced in the emergency room or the urgent care center. The providers basically just open up the cavity like for any zit or cyst or abscess, and they drain the fluid. You put gauze on there and you let it heal. That’s what we do the first time it happens.

Now if this disease keeps reoccurring, then the treatment is two folds. One is removing it and doing it in such a way to help prevent reoccurrence of the disease. There are various surgical options. Unfortunately, the medical options are limited. You can take antibiotics for the first or second attack and see if that helps it go away, but it’s not going to prevent the disease from reoccurring. To really cure yourself of the disease, you need the cyst removed surgically.

Host: So, do they come back once they're removed surgically?

Dr. Kermani: They shouldn’t. But, you know, the main risk is not completely excising all of them and then having to go back and excise more tissue. I've had many patients who’ve had their cyst removed previously, and that seemed to help them. Then even as late as 10/20 years later, they may come back with a reoccurrence of the disease because it turned out there were cysts located more peripherally that the original surgeon didn’t appreciate at the time. So, the cysts reoccurred. But once you excise all of the cysts, they shouldn’t come back. There are various techniques that we have for excising the cysts depending on how complex your disease is.

Host: Dr. Kermani, are these genetic? If you know that one or two of your parents had something like this, does that seem to follow in families?

Dr. Kermani: We do tend to see a genetic component to them, but like most diseases it’s partly genetic, partly environment. So, you could be born with these cysts, and if you're not that physically active or you're not that hairy in the area, it’s never going to bother you. Whereas if you inherit these cysts from your family and you happen to be very hairy back there or you're very athletic or you're constantly moving around, then you're more likely to get to develop the problem. So, having the cyst itself is genetic, but whether or not it will become symptomatic, that is more environmental and has to do with the amount of physical activity.

In fact, in World War II, they used to call this Jeep rider syndrome because the soldiers who were riding jeeps would frequently have a very bumpy ride for these long drives. That would irritate their tailbone so much that it would lead to a series of pilonidal infections. So, there was a little outbreak of them during the World War II era. But like I said, like most diseases, it’s partly environmental and partly genetic.

Host: What an interesting aspect to all of this. Wrap it up for us Dr. Kermani. Just what you want the take-home message about this unusual disease that can be quite painful, and the treatment options available.

Dr. Kermani: Sure. I want to let you guys know that here at Palmdale, we have options available for us. So, I like to treat this disease… Most patients, first of all after their first attack, do go on to have multiple attacks. I always tell the patient practice good hygiene, shave the area, but if this comes back definitely come see me while it’s still acutely effected so I can look at that area. Because sometimes what happens is the cyst will get infected or inflamed. The inflammation wears off, and then we can't even tell its there anymore. So, it’s good to have your doctor or your surgical consult look at it as soon as possible.

Then what I like to do is there’s a minimally invasive technique that first was promoted by a surgeon out in India, Dr. Gips. He does what he calls minimally invasive pilonidal surgery where he literally goes, and he plucks out these cysts individually with special surgical instruments. He’s seen an 80% cure rate, which is actually quite good. Me and some colleagues in the states have been basically copying his techniques, and we’ve had pretty good outcomes. Without having to give the patient a very large, extension resection of the area, we go ahead, and we pluck out these cysts with our special instruments. Most of the time the patients heal up quite well.

For the 10 to 20% that do occur, I then offer a more extensive surgery. We excise a much greater amount of tissue to make sure we get out all of the cysts. Then what I do is I employ a plastic surgery technique called myocutaneous flaps where I literally get the muscle and fascia of the buttock tissue, of the gluteus, and I rotate it to cover up the hole left by where the pilonidal cyst used to be. That tends to be a more involved surgery and I tend to save that for the patients with the more severe disease who fail the minimally invasive approach where we just literally simply take out the cyst.

Host: How interesting. Thank you so much Dr. Kermani for coming on today and sharing your expertise and explaining what these are and the treatment options available. Thank you again. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit palmdaleregional.com. That’s palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if this type of surgery might be right for you. This is Melanie Cole. Thanks so much for listening.