Pilonidal is an abscess, usually

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1 Welcome to GPN s learning zone. By reading the article in each issue you can learn all about key principles of subjects that are vital to your role as a general practice nurse. Once you have read the article, visit co.uk/learning-zone/ to evaluate your knowledge on this topic by answering the 10 questions in the e-learning unit; all answers can be found in the article. If you answer the questions correctly, you can download your certificate which can be used in your continuing professional development (CPD) portfolio as evidence of your continued learning and contribute to your revalidation portfolio. Pilonidal is an abscess, usually found in the natal cleft, most frequently caused when a ruptured hair follicle beneath the skin becomes infected forming an abscess (pilonidal cyst) filled with hair, keratin and debris which can develop into a sinus tract (sacrococcygeal fistula) (Pilonidal Support Alliance [PSA], 2011; Harris et al, 2012) (Figure 1). Pilonidal wounds are painful and distressing and can be a complex problem, requiring time-consuming wound care (Timmons, 2007). The term pilonidal is from the latin pilus (hairs) and nidus (nest) (Miller and Harding, 2003). Hair is not always the cause of a pilonidal abscess. In females, the cause is more usually a swollen or ruptured follicle without hair (Notaras, 1970; PSA, 2011). Complications often occur following surgery to excise or lay open the sinus, with cost implications for the NHS in terms of surgical procedures, inpatient stays, medication and postoperative wound care in the community (Harris et al, 2012). Pilonidal sinus wounds are more common in young people. The peak onset is between 19 and 22 years of age (Harris et al, 2012), potentially resulting in loss of earnings for time taken off work (Bannerjee, 1999), as well as being a source of embarrassment and discomfort (Timmons, 2007), and impacting on Diagnosing and managing pilonidal sinus disease Rosemary Rose Tissue viability clinical nurse specialist, Walsall Healthcare NHS Trust psychological wellbeing (Stewart et al, 2012). They are rarely seen beyond the age of 45 (Marza, 2013). CLINICAL PRESENTATION The incidence of pilonidal sinus is 26 per 100,000 (Bradley, 2006). Recent National Institute for Health and Care Excellence Clinical Knowledge Summaries (NICE CKS, 2014) and Marza (2013) state that the condition is more likely to occur (see also Table 1): In males (male/female ratio being 4:1; Harris et al, 2012) Being aged years Being white European Unusual male hair growth in women (Hirsutism) Having a deep pit in natal cleft Having an occupation which involves long periods of sitting If there is a family history Being obese. Pilonidal wounds are not only found in the natal cleft, they can also occur in interdigital spaces in barbers hands, the axilla, umbilicus and in above-knee amputation stumps, although this is far less common than in the natal cleft (Uysal et al, 2003). There are two main theories for pilonidal sinus disease, these are congenital and acquired. Congenital theory Before the 1960s it was believed that pilonidal sinus was congenital due to a natural deep pit or dimpling found in the natal cleft where hair and? Did you know... During the second world war, sacrococcygeal pilonidal sinuses were named Jeep disease because many jeep drivers developed them as a result of driving for long periods over rough ground, which caused trauma to hair follicles (Bannerjee, 1999). dead skin cells collect resulting in a sinus (Timmons, 2007; Hashmi, 2008; Stephen-Haynes, 2008). Acquired theory More recently, Bascom (1983) discovered that a hair follicle swollen with keratin (caused by the onset of puberty, Hashmi, 2008) would create an inflammatory response (exacerbated by further hairs growing into the track), folliculitis and eventually an abscess. Once the follicle ruptured an epithelium lined track resulted. Table 1: Risk factors for developing pilonidal sinus (Marza, 2013) Obesity Sedentary occupation, e.g. sitting for over six hours a day, driving for long periods Local irritation or trauma before symptoms start, e.g. folliculitis in the perianal area Family history (one or more family members have pilonidal sinus disease [PSD]) Having a great deal of hair surrounding the sinus GPN 2015, Vol 1, No 1 85

2 Credit: FIGURE 1. Pilonidal sinus. Clinical presentation can be categorised according to severity: Asymptomatic: patients might discover the cyst/abscess themselves, or it is spotted during routine anorectal clinical examination (Stephen-Haynes, 2008) Acute: patients typically present with moderate-to-severe pain in the region of the natal cleft or lower back. A sacrococcygeal abscess with exudate may be present (Stephen- Haynes, 2008), as well as cellulitis (NICE CKS, 2014) Chronic: patients present with recurring infections in the sacrococcygeal area. Skin may be broken or unbroken (Bannerjee, 1999). Antibiotics should be prescribed to avoid surgical intervention (Stephen- Haynes, 2008) Complex or recurrent pilonidal sinus disease: this occurs when there is recurring infection in nearby follicles or hairs entering the wound while it is healing (Bannerjee, 1999). If left untreated, the sinus will become lined with squamous epithelium (Bannerjee, 1999). NICE CKS (2014) state that approximately 50% of acute pilonidal sinuses may become chronic, despite treatment. TREATMENT OPTIONS The treatment regimen will depend on the clinical presentation (Table 2). Individual assessment should be carried out and lifestyle should be considered when deciding treatment (Bannerjee, 1999). The anatomical location of the wound and its association with poor hygiene can lead to feelings of embarrassment. Patients may be concerned about recurrence and the risk of further infection. Meticulous hygiene is key in promoting wound healing and preventing recurrence, and washing after each bowel movement should be recommended (Harris et al, 2012). NICE CKS (2014) acknowledge that the benefits of shaving are debatable, as studies surrounding hair removal are limited and based on postoperative patients. If inpatient treatment is needed, on admission, baseline observations and medical history should be documented (Timmons, 2007). Pain needs to be managed carefully preand postsurgery (Stephen-Haynes. Table 2: Symptoms and management of pilonidal sinus (adapted from Marza, 2013) Symptoms Treatment Asymptomatic Small pit/dimple or swollen area May be painful Symptomatic 2008), with patients being offered pain relief medication as needed (NICE CKS, 2014). Conservative methods A conservative approach is usually considered for patients presenting with mild symptoms. Antibiotics should be prescribed to combat infection, prevent sepsis and future surgery (Stephen-Haynes, 2008). Where small, non-infected sinuses are present, clinicians in primary care with appropriate skills may remove the hair with forceps and clean out the track (NICE CKS, 2014). A phenol injection can be administered into a non-infected sinus to schlerose and close it (Stephen-Haynes, 2008). This practice is diminishing, possibly due to the associated pain and the need for repeated injections (Bradley, 2006). This method has not been linked with effective results, however, Dogru et al (2004) identified a low recurrence of 5% with this method. Surgical interventions Broad spectrum antibiotics should be given before any surgical management where cellulitis or purulent exudate are present (Timmons, 2007). Incision and drainage may be required for an acute pilonidal sinus, with excision of the pits at a later date once inflammation has subsided (Bascom, 1983). There is a high incidence of abscesses recurring with Antibiotic therapy if needed Painkillers as required Monitoring (keeping the area clean and dry) Acute Chronic Complex or recurring With or without malodorous discharge (pus and blood) Swelling With or without cellulitis Antibiotic therapy Surgery Discharge Multiple sinuses may be present Abscess Inflammation/oedema Antibiotic therapy if needed Discharge Infection Abscess Antibiotic therapy Surgery 86 GPN 2015, Vol 1, No 1

3 Now on Drug Tariff Exufiber - the future of fiber dressings Superior retention 1 Easier removal Exufiber is a unique gelling fibre dressing with Hydrolock Technology which addresses the challenges of highly exuding wounds. Superior retention capacity 1 reduces risk of leakage and maceration. Excellent tensile strength enables removal in one piece. Together with a secondary dressing with Safetac technology, Exufiber creates a unique treatment option for highly exuding wounds. Visit to find out more and request free samples. References 1. SMTL method TM-404 for Free Swell Absorbtion and Retention. Test performed at SMTL, UK. Laboratory report Molnlycke Health Care, Arenson Centre, Arenson Way, Dunstable, Bedfordshire, LU5 5UL. Telephone: info.uk@molnlycke.com. The Mölnlycke Health Care, Exufiber and Safetac trademarks, names and logo types are registered globally to one or more of the Mölnlycke Health Care Group of Companies Mölnlycke Health Care AB. All rights reserved.

4 this method, but identifying and excising the sinus a few days after drainage can reduce this risk (in 85% they will not recur; Bannerjee, 1999), and the abscess should be entirely removed (Stephen- Haynes, 2008). Early recurrence usually occurs when not all sinus are identified and removed, and late recurrence (beyond six months postoperatively) can occur due to tension along the midline cleft, or repeated build up of hair and debris (Marza, 2013). Wide excision The sinus is laid open and allowed to heal by secondary intention, resulting in a 58% lower risk of recurrence than with primary closure (Al-Khamis et al, 2010). This method can prolong healing by up to 6 8 weeks and, in some cases, longer than six months due to repeated infection (Stephen-Haynes, 2008). Flap surgery This method may be used where patients experience recurring pilonidal sinus (Stephen-Haynes, 2008). A donor layer of skin and fascia with its own blood supply is applied to the wound bed. Although this method reduces recurrence (Timmons, 2007), it involves longer inpatient stays (Ajaz et al, 2007). Laser hair removal This method, used in conjunction with surgery to remove a sinus, has been found to reduce recurrence rates (Marza, 2013). It is important that patients are fully informed about the surgical procedure they are to undergo, as the size of the wound postoperatively may otherwise come as a shock (Timmons, 2007). Any fears and concerns relating to self-esteem, body image and pain should be discussed and explored, with the possibility of recurrence and infection also being explained (Stephen-Haynes, 2008). A recent study concluded that the pain, physical inactivity, altered body image and delayed wound healing following pilonidal sinus surgery has a psychological impact (Stewart et al, 2012). POSTOPERATIVE NURSING CARE Regardless of which surgical procedure is undertaken, optimal postoperative wound care is vital for successful healing (Ajaz et al, 2007). An holistic wound assessment should be carried out and the psychological effect of the wound on the patient addressed (Bradley, 2006; Timmons, 2007). Strategies for assessing, managing and documenting pain with wound care should be applied (European Wound Management Association [EWMA], 2002). Postoperative wound management Postoperatively, infection can cause complications, resulting from bacteria in the tissue, or the close proximity of the wound to the anus which increases the risk of bacterial contamination, as hair in the periwound skin can collect faeces and debris (Harris and Holloway, 2012; Murphy and Powell, 2013). The T.I.M.E. framework should be applied to assess wound tissue, inflammation, moisture levels and edges, and the effect that the wound might be having on the patient s wellbeing should be observed, with all findings documented (Vuolo 2009). The main aims of wound management are to (Timmons, 2007): Prevent infection Reduce the risk of sinus recurrence Promote healing from the wound bed Accelerate re-epithelialisation with good cosmetic results. The wound should be observed for the following signs of infection: Malodorous discharge Increased volumes of exudate Friable granulation tissue Epithelial tissue bridging across the wound Cellulitis Increased pain Redness Raised temperature Delayed healing. Some of these signs may also be indicative of inflammation while healing, so this needs to be considered! What s your next step To use the knowledge that you have gained from this article to inform your continuing professional development (CPD), you should take the following steps before logging onto the website to take the learning zone test: Reflect Do you understand what pilonidal sinus disease is? Are you able to identify the different degrees of severity? Do you understand the different treatment options? Evaluate Do you appreciate why it is important to provide comprehensive holistic care postoperatively? Act Read the article when you have a few spare minutes in the day. Make some notes on what you have learned, then visit the online test (www. journalofpracticenursing.co.uk/ learning-zone/) to complete this subject. The whole test, which involves reading this article and answering the online questions, should take you 90 minutes to complete. Finally, download your certificate to show that you have completed the GPN e-learning unit on pilonidal sinus disease as part of your CPD portfolio. when assessing the wound for infection (Stephen-Haynes, 2008). Bradley (2006) suggested that the ideal dressings for patients with pilonidal wounds that are healing by secondary intention should be ones that are able to absorb exudate, prevent leakage and be easy to apply and remove without causing pain to the patient. Stephen-Haynes (2008) recommended the following 88 GPN 2015, Vol 1, No 1

5 dressings to manage pilonidal sinus wounds: Absorbent dressings alginates/ gelling fibres Cavity dressings to keep wound edges separated to prevent dead space occurring Foams to prevent leakage and infection Antimicrobial dressings to reduce critical colonisation or where there is risk of infection Negative pressure wound therapy where high volumes of exudate are present. Due to the young age of this patient population, it is important that healthcare professionals inform and involve the patient in the dressing choice to enable and encourage them to continue their activities of daily living. Patient involvement and empowerment can help to lessen anxieties during the healing process (Tinsley, 2002). Bradley (2005) reported that some patients with wounds healing by secondary intention stopped playing sport due to concerns about dressingz slippage or sweating causing infection. Promoting selfcare through regular, thorough washing and applying dressings can help to motivate patients in their care and to continue their normal activities (Bradley, 2006). It should be acknowledged that daily dressing changes for an open wound can be disruptive to a young person s routine. Pain levels should always be monitored and appropriate pain relief given. This is particularly important postoperatively and at dressing changes (Stephen-Haynes, 2008). CONCLUSION Pilonidal sinus is a benign disease mostly affecting the young, which can be extremely painful and debilitating. For symptomatic pilonidal disease, treatment may involve surgical intervention such as incision and drainage. The management of pilonidal wounds can be challenging, but with a systematic approach to wound care and involving the patient in their care to help prevent infection and recurrence of this painful disorder, positive results can be achieved. Treatment should not prevent patients from returning to normal activities of daily living (both social and work-related), which should be achieved as quickly as possible. Psychological care is as essential as nursing care when managing this disease. GPN This article was sponsored by an educational grant from Mölnlycke Health Care. REFERENCES Ajaz S, Alwarasdeh W, Porrett TRC, Lunniss PJ (2007) Aetiology, presentation and management of pilonidal disease. Gastrointestinal Nurs 5(5): 20 6 AL-Khamis A, McCallum I, King PM, Bruce J (2010) Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database of Systematic Reviews 4: CD Bannerjee D (1999) Pilonidal sinus wounds: the clinical approach. J Community Nurs 13(12): 22 6 Bascom J (1983) Pilonidal disease: long term results of follicle removal. Dis Colon Rectum 26(12): Bradley L (2005) The lived experience of young adults with chronic pilonidal disease. Free paper session. Proc EWMA Conference, Stuttgart, September Bradley L (2006) Pilonidal sinus disease: a misunderstood problem. Wounds UK 2(1): Dogru MD, Carnei C, Aygen E, Girgin M, Topuz O (2004) Pilonidal sinus treated with crystallised phenol: an eight-year experience. Dis Colon Rectum 47(11): 19 European Wound Management Association (2002) Position Document. Pain at Wound Dressing Changes. MEP, London Harris CL, Holloway S (2012) Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified Reactive Delphi procedure. Part 2: methodology, analysis and results. Int Wound J 9(2): Harris CL, Laforet K, Sibbald RG, Bishop R (2012) Twelve common mistakes in pilonidal sinus care. Adv Skin Wound Care 25(7): Hashmi T (2008) Dermatology treating pilonidal sinus. Independent Practice point Pilonidal sinus disease should be considered if a patient presents with recurrent, unexplained pain in the coccyx area. Nurse 6. Available online: www. magonlinelibrary.com/doi/full/ / indn (last accessed 18 April, 2015) Marza L (2013) Reducing the recurrence of pilonidal sinus disease. Nurs Times 109(25): 22 4 Miller D, Harding K (2003) Pilonidal sinus disease. World Wide Wounds. Available online: december/miller/pilonidal-sinus.html Murphy S, Powell G (2013) Pilonidal sinus wounds: successful use of the novel negative pressure wound therapy device PICO. Wounds UK 9(4): 80 8 National Institute for Health and Care Excellence (2014) Pilonidal sinus disease. CKS. NICE, London Notaras MJ (1970) A review of three popular methods of treatment of postanal (pilonidal) sinus disease. Br J Surg 57(12): Pilonidal Support Alliance (2011) What is it? Available online: education/whatisit.php (last accessed 26 April, 2015) Stephen-Haynes J (2008) Pilonidal sinuses: aetiology and nursing management. Wound Essentials 3: Stewart A, Baker JD, Elliott D (2012) The psychological wellbeing of patients following excision of a pilonidal sinus. J Wound Care 21(12): Timmons J (2007) Diagnosis, treatment and nursing management of patients with pilonidal sinus disease. Nurs Standard 21(52): Tinsley P (2002) The management of a pilonidal sinus and its follow-up care. Br J Nurs (tissue viability suppl) 11(20): S31 S6 Uysal AC, Alagoz MS, Unlu RE, Sensoz O (2003) Hairdresser s syndrome: a case report of an interdigital pilonidal sinus and review of the literature. Dermatol Surg 29(3): Vuolo J (2009) Wound Care Made Incredibly Easy. Lippincott, Williams & Wilkins, London GPN 2015, Vol 1, No 1 89