Technical Options in Treatment of Pilonidal Sinus and Hidradenitis Suppurativa

ta tion. Ab scess, chronic si nus, com plex ity of si nus, chronic re cur rent of pilonidal ab scess af fects the treat ment strat egy. Each state ment has dif fer ent man age ment op tion but wide, me tic u lous shav ing and hy giene al ways should be main part of the all of the man age ment op tions. In pa tients, pre sent ing ini tially with sim ple midline pits or si nus tracts with out acute ab scess shav ing can be of fered as the ini tial treat ment. Dur ing both pri mary and post op er a tive heal ing phase, shav ing should be con tin ued on a weekly treat ment. Pa tients with acute pilonidal ab scess re quire in ci sion and drain age, ide ally mak ing the in ci sion lat eral to the midline. Dress ing change, baths and shav ing should be con tin ued un til the wound has healed. The ma jor ity of acute ab scess treated in this way do not oc cur.Many pa tients will pres ent ini tially with chronic pilonidal si nus. Lo ca tion of the si nus will help to choice to man age ment way. In the case where all the dis ease si nuses and pits are lo cated near and in the midline, the con ser va tive midline ex ci sion or unroofing with cu ret tage may be the first step treat ment. How ever if the mul ti ple drain ing si nuses ex ist and they are lo cated far away from the midline, the sim ple ex ci sion may cause large wound de fects. In these sit u a tions cleft lift pro ce dures (Bascom) or ex ci sion with a rhom boid flap re con struc tion. These pro ce dures are also avail able for the re cur rent dis ease or af ter failed pri mary midline ex ci sion op er a tions. How ever, con ser va tive treat ment meth ods have lit tle or no ef fects on per i neal/perianal e x t e n s i v e hidradenitis suppurativa. Pa tients clas si fied as Hurley stage III are usu ally re ferred for wide ex ci sion and re con struc tive sur gery. There fore, sur gi cal to tal ex ci sion must be con sid ered even in the early stages of the dis ease to pre vent fur ther com pli ca tions, such as ab scesses, si nus tract and, fis tula for ma tions, and scar ring. Man age ment of the wound af ter to tal ex ci sion should be tai lored to the in di vid ual pa tient. Al though the in ci dence of squamous cell car ci noma is rare but it is the most se ri ous com pli ca tion of HS. The di ag no sis and treat ment of anal fis tula and anorectal in fec tion is a cor ner stone of any busy and ded i cated co lon and rec tal sur geons’ prac tice. Pilonidal si nus (PS) is not strictly a dis ease of the anus, be cause of its prox im ity to the anus and the oc ca sional dif fi culty in dif fer en ti a tion from anal fis tula, these pa tients com monly re ferred to a co lon and a rec tal sur geon for the treat ment. Hidradenitis suppurativa (HS) which oc curs more fre quently in other ar eas of the body can be a di ag nos tic prob lem when it has seen and sus pected in per i neal area. Both PS and HS may pres ent as a pro longed and long-suf fer ing course of treat ment for the pa tient and sur geon. This pa per re viewed the treat ment op tions of PS and HS briefly.

e m i z e r army 5 .Pilonidal si nus prob lem with long term med i cal and sur gi cal treat ments can be sig nif i cant source of mor bid ity and dis abil ity.
Tra di tion ally, treat ment op tion was wide lo cal sur gi cal ex ci sion for PS.Nearly 80.000 sol diers were hos pi tal ized for av er age of 55 days for wound heal ing af ter PS surgery I dur ing World War II 6 .World War II caused a major change in man age ment and treat ment op tions of PS such as non-op er a tive mo dal i ties (shav ing and hy giene) to op er a tive mo dal i ties (ex ci sion and flap re con structions).Man age ment of PS should be tai lored to in di vidual clin i cal pre sen ta tion but we should re mem ber none of the so many treat ment op tions has proved com plete sat isfac tion [3][4][5][6][7] .
Pathogenesis of the PS is also con tro ver sial.In the begin ning it is be lieved as a con gen i tal dis ease but cur rently PS is ac cepted as an ac quired con di tion re lated to presence of hair in the gluteal cleft area 8 .In the mech a nism of PS, trans-der mal pen e tra tion of loose hairs in the na tal cleft and a for ma tion a for eign body re ac tion into the subcu ta ne ous tis sue, is the most ac cepted the ory.][7][8] The clin i cal pre sen ta tions spec trum of PS var ies from a chron i cally in flamed area and/ or si nus with per sis tent drain age to more acute pre sen ta tion of an as so ci ated abscess or ex ten sive sub cu ta ne ous tracts 9 .

CLIN I CAL EVAL U A TION
The di ag no sis of PS is most of ten a clin i cal find ing in the gluteal cleft.][11][12] On phys i cal ex am i na tion, the pres ence of midline pits in the gluteal cleft, some times with hair or de bris ex truding from the open ings is pathognomonic for PS.Ad dition ally, in acute set tings pa tients may pres ent with cellulitis or a pain ful, fluctuant mass in di cat ing the presence of an ab scess.The chronic state is most of man ifested by chronic drain ing si nus dis ease in the inter-gluteal fold and/or re cur rent ep i sodes of acute in fections.It is also im por tant to per form a thor ough anorectal ex am i na tion to eval u ate for con com i tant fis tu lous disease, Crohn's dis ease, or other anorectal pa thol ogy.Addi tional lab o ra tory or ra dio log i cal workups are not routinely nec es sary [13][14][15][16]

TREAT MENT
There are many treat ment op tions de scribed in the lit era ture but sim ply they can be cat e go rized in two groups: nonsurgical and sur gi cal.

NONSURGICAL METHODS
Treat ment of chronic PS, shav ing alone has been ad vocated as an al ter na tive to sur gery.Armstrong and Barcia 17 tested this hy poth e sis that wide care ful shav ing is equal or su pe rior to sur gi cal ther apy of any kind of chronic PS.The au thors per formed a pi lot nonrandomized co hort study ret ro spec tively.One group of pa tients was treated with weekly strip shav ing un til heal ing oc curred and the other group was treated with sur gery.Then they fol lowed the pa tients for 3 years, com par ing the num ber of oc cupied bed days and num ber of op er a tions re quired.The au thors found highly sta tis ti cally sig nif i cant dif fer ence in fa vor of the group re ceived only shav ing with lower num ber of oc cu pied bed -days, with only 23 op er a tions re quired in 101 con sec u tive cases of con ser va tive manage ment with weekly shav ing.Al though this study shows sig nif i cant ben e fit for shav ing alone.The weak ness of this study is the au thors did not con trol and com pare the types of sur gery per formed in non-con ser va tive group or for the se ver ity of dis ease.Heal ing and re cur rence rates were not re ported also.Fur ther more, the con ser va tively treated pa tients were not oc cu py ing hos pi tal beds.Despite these lim i ta tions, this study pro vides ev i dence that shav ing as a treat ment of PS, ef fec tively con trols PS in the non-op er a tive out pa tient set ting while pro mot ing near-nor mal work sta tus and is pre ferred over excisional meth ods.
The use of phe nol (so lu tions or crys tals) , with cau tious pro tec tion of sur round ing skin, re moval of si nus hairs and de bris with for ceps as well as lo cal shav ing is one of the prom is ing nonsurgical meth ods.Small se ries have dem on strated suc cess rates rang ing from 60-95% 18 .Even in the set ting of re cur rent chronic si nus dis ease, phe nol and lo cal de pil a tory cream ap pli ca tions on a weekly ba sis has shown low re cur rence rates (0-11%) at long term fol low ups 19 .

SUR GI CAL METH ODS
Sur gi cal treat ment of PS has many op tions from sim ple in ci sion and drain age to wide ex ci sions and flap re construc tions [20][21][22] .Sur gi cal treat ment in cludes incisional and excisional pro ce dures with or with out dif fer ent clo sure tech niques.As the ac quired the ory for PS has gained wide ac cep tance, wide ex ci sion tech niques have fallen out of fa vor.Now a days min i mally ag gres sive sur gi cal tech niques for PS are ac cepted as the treat ment of choice, and be came very pop u lar 23 .The ben e fit of the patient is by de creas ing the hos pi tal stay and min i miz ing the mor bid ity.
For acute PS with ab scess or with out as so ci ated cellulitis, the main sur gi cal ap proach is still drain age and cleans ing of the ab scess cav ity fol lowed by reg u lar outpa tient ba sis un til com plete heal ing 24 .Af ter sim ple drainage pro ce dures for the first at tack of acute PS, over all heal ing rates have been re ported ap prox i mately 60%, the un healed rest of them has been needed an ad di tional oper a tions [25][26][27] .Dur ing the fol low up pe riod, re cur rent dis -  ease af ter com plete heal ing oc curs in nearly 10-15%, which cor re spond, to a higher re cur rence rates 28 .Chronic form of PS pres ents its self with re cur rent abscesses with in ter val pe ri ods of com plete res o lu tion or per sis tent non-heal ing, drain ing wound.The sur gi cal treat ment of chronic dis ease is gen er ally di vided in two cat e gory: ex ci sion &pri mary clo sure, ex ci sion & sec ondary heal ing.
Most chronic PS are lo cated midline, there fore the most com mon op er a tion is midline ex ci sion with or with out pri mary clo sure.En bloc, ex ci sion is made of the en tire pilonidal si nus.It is not nec es sary to al ways ex cise down to presacral fas cia.In sec ond ary heal ing tech nique, the wound can be packed with moist gauze and dress ings are changed daily.Ex ci sion with sec ond ary heal ing is as so ciated with pro longed heal ing times.Fuzun et al 29 ran domized 91 pa tients to ei ther ex ci sion with out clo sure or exci sion with pri mary clo sure.In the study, the post op er ative min i mum fol low up pe riod was 4 months.The primary end point of the study was in fec tious and re cur rence rates.No an ti bi ot ics was used in the study.Pa tients whose wounds were left open had a lower in fec tion rate (1.8% vs. 3.6% p<0.01) and there is dif fer ence in terms of re cur rence rate (open group 4.4% vs. 0% p<0.01).
The util ity of an ti bi ot ics has been eval u ated in three situ a tions: Perioperative pro phy laxis, post op er a tive treatment, and top i cal use.In pro phy lac tic set ting, lim ited data is avail able in the lit er a ture.An in tra ve nous sin gle dose be fore ex ci sion and pri mary clo sure of chronic PS re sulted in no dif fer ence in wound com pli ca tion or healing rates in com par i son with those not re ceiv ing an ti bi otics 30 .One small, ran dom ized, blinded study com par ing sin gle dose pro phy lac tic metronidazole ver sus cefuroxime and metronidazole pre op er a tively fol lowed 5 days oral ampicillin sulbactam dem on strated no dif fer ence in wound in fec tions at 1 week 31 .There was no dif fer ence in over all wound heal ing was iden ti fied in com par i son of 1 and 4 day courses of perioperative metronidazole and ampicillin fol low ing ex ci sion and pri mary clo sure 32 .In post op er a tive set ting, an ti bi ot ics have shown mixed results.As an ad junct to pri mary ex ci sion in chronic pilonidal dis ease com par ing those left to heal by sec ondary in ten tion, fol low ing pri mary clo sure, or un der go ing pri mary clo sure plus 2 weeks of clindamycin 33 .Of the 3 groups, only sec ond ary in ten tion was as so ci ated with the de layed heal ing.On the other hand, the ad di tion of metronidazole for 14 days or metronidazole with erythromycin fol low ing ex ci sion and sec ond ary in ten tion wound heal ing of chronic PS showed a slightly shorter heal ing times for the an ti bi otic group than with out an ti bi otic group 34 .In ad di tion, there was no dif fer ence in wound heal ing with dou ble cov er age erythromycin ther apy.Additional stud ies us ing lon ger du ra tions of va ri ety of a sin gle -and dou ble cov er age an ti bi otic reg i mens have failed to dem on strate any clear ad van tage [35][36][37] .
The use of top i cal an ti bi otic reg i mens have con flicts and con tro ver sies in the treat ment of PS.Only one re port showed sig nif i cantly higher wound heal ing rates ( 86% vs. 35% p<0.001) af ter ex ci sion of chronic dis ease or pre vi ously drained acute ab scess and pack ing with an absorbable gentamicin im preg nated col la gen based sponge with over ly ing pri mary wound clo sure than without an ti bi otic pack ing 38 .Un for tu nately, the con tri bu tions of the gentamicin could not be sep a rated.A more re cent study com par ing pri mary clo sure over gentamicin soaked sponge ver sus sec ond ary heal ing showed quicker heal ing and lower cost in closed group 39 .On the other hand another in ves ti ga tion con cluded that there was no ben e fit to clo sure over the sponge ver sus clo sure with out it 40 .Overall, the util ity of an ti bi ot ics in top i cal or sys temic ap plica tions re mains un clear.Ad junc tive use should be con - sid ered in the set ting of se vere cellulitis, un der ly ing immunosuppression or with sys temic dis ease 41 In both the ad junc tive role to pri mary sur gi cal treatment and a re sult to pre vent re cur rence, shav ing (along with hy giene en force ment and lim ited lat eral in ci sion and drain age of ab scess) has been shown that less length of stay in hos pi tal, less sur gi cal pro ce dures, and ear lier return to work in terms of all sur gi cal pro ce dures 42 .Shaving along the intergluteal fold and sur round ing area has also been used as a stan dard part of the post op er a tive treat ment in var i ous sur gi cal tech niques [42][43][44] .The most effec tive fre quency and ex tent of shav ing yet to be clar ified.La ser epilation has been ap proved for pri mary and sec ond ary PS 44 .
For pa tients who un der went pri mary wound clo sure, the heal ing pe riod have some clear ad van tages in the off midline group to midline clo sure group.Lim ited and conflict ing data is avail able com par ing the efficacies of ex cision with marsupialization to pri mary clo sure.In gen eral pri mary clo sure is as so ci ated with quick heal ing times with higher re cur rence retes [45][46][47] If the sur geon pre fers to do a pri mary clo sure ( ex cept flap tech niques) off midline tech nique must be the preferred ap proach (ver ti cal or oblique) This has con sis -tently dem on strated faster heal ing pe riod, lower re currence and wound mor bid ity rates [45][46][47] .
The other main sur gi cal op tions are ex ci sion and flap tech niques.These tech niques are fa vor able in both primary and re cur rent dis eases.There are many flap op tions such as Karydakis, Z, rhom boid, Limberg.In the flap tech niques, all si nuses are re moved down to the presacral fas cia and ro ta tion of a fasciocutaneous flap (Fig ure 1) that re sults in flat ten ing of gluteal cleft [45][46][47] .Over all results are fa vor able with re spect to dis ease re cur rence (0-6%) and heal ing pe riod [48][49][50] .The data from ran domized tri als found low (0-6%) over all rates of sur gi cal site in fec tions [50][51][52][53] .Ad di tional data in di cate sig nif i cantly lower re cur rence rates af ter rhom boid flaps tech niques vs. V-Y ad vance ment flaps a no dif fer ences were found in wound com pli ca tions, seroma for ma tion or length of hos pi tal stay 54 .
The Karydakis flap is a pop u lar and easy flap tech nique that uses a mo bi lized fasciocutaneous flap se cured to sacrococcygeal fas cia with lat eral su ture lines.Karydakis re viewed his per sonal se ries of more than 6000 pa tients treated with this tech nique in 1992, with a re cur rence rate less than 2% and wound com pli ca tions 8% 5 .Sim i lar findings re ported in case se ries with this tech nique [55][56][57] .In a sin gle ran dom ized, con trolled study com par ing the Karydakis pro ce dure with open heal ing Karydakis re pair resulted in a 6% re cur rence rate, 20% wound mor bid ity, and 98%over all heal ing rate at a fol low up three years 58 .In two ran dom ized tri als, Karydakis and Limberg flaps were eval u ated and two flap pro ce dures were found rel atively equal in terms of post op er a tive cresults 59 .
The cleft lift tech nique also cre ates a flap based cov erage with clo sure off midline, oblit er at ing the cleft al together.Bascom and Bascom, 60 have re ported suc cess ful heal ing in 28 re cur rent and com pli cated PS.Ad di tional case se ries con firmed heal ing rates of over 80% to 95% in both pri mary and re cur rent set tings [61][62][63] .Wright 64 et al, showed slightly higher re cur rence rates of 12% in cleft lift tech nique.Sev eral other flaps have been used for PS in clud ing V-Y ad vance ment and Z-plasty tech niques.Mi nor wound com pli ca tions, > 90% heal ing and low recur rence rates have been re ported in the se ries [65][66][67] .

HIDRADENITIS SUPPURATIVA IN TRO DUC TION
Verneuil's 68 dis ease, or hidradenitis suppurativa, is a chronic sup pu ra tive dis ease with a ten dency to si nus forma tion, fi bro sis, and scle ro sis.It is a dis ease of the apocrine sweat glands and may arise from each of the local iza tions where apocrine glands are prom i nent: axilla, nip ples, um bi li cus, per i neum, groin, and but tocks [68][69][70] .Exten sive hidradenitis suppurativa of the per i neal/perianal and the gluteal re gions con sti tute a se ri ous so cial problem.
Al though the pathophysiology is poorly un der stood, the gen eral be lief is that the ob struc tion of the apocrine and/or follicular pores re sults with the di la ta tion of the glands and bac te rial super in fec tion fol lowed by the rup -  ture of the glands and the dis sem i na tion of in fec tion through out the sub cu ta ne ous tis sue planes 71 .In con trast, some au thors claim that de spite its suppurativa na ture, HS is al most cer tainly not a dis ease ini ti ated by in fec tion and is prob a bly a con di tion not even pri mar ily af fect ing the (apocrine) sweat glands 72 .
In ad di tion to be ing re lated to obe sity, there are many other myths as so ci ated with HS, such as di a be tes mellitus, poor hy giene, de odor ants, and chem i cal depilation 72,73 .The dis ease al most al ways oc curs af ter pu berty and be fore aged 40 years lead ing to the the ory that there is a hor monal com po nent in the pathogenesis.There also seems to be a ge netic com po nent, and in one study of 110 pa tients, 38 per cent re ported a fam ily his tory of this disease.This may re flect a fa mil ial form with autosomal dom i nant in her i tance [72][73][74][75] .

SYMP TOMS AND FIND INGS
Pa tients mostly have re cur rent pain ful ab scesses and mal odor ous dis charge ne ces si tat ing reg u lar dress ings, the dis ease is highly de bil i tat ing for suf fer ers both phys i cally and psychologicaly lead ing to so cial iso la tion, failed re lation ships, and de pres sion.HS is seen pre dom i nantly in the axillary area and of ten is self-lim it ing, rarely re quiring a sur gi cal pro ce dure.How ever per i neal, perianal, and gluteal HS usu ally re quires some form of sur gi cal treatment.The clin i cal as pect is some times very specular: the deep-seated ab scesses and si nus are closely as so ci ated in a unique le sion slowly ex tend ing at the pe riph ery dur ing a pe riod of years.The le sions may be very large, sol i tary, and deep.Such sin gle macro le sions may be mis taken for reg u lar ab scesses of the mus cle or even bone-de rived lesions.There fore, le sions of the but tock are eas ily dif feren ti ated from su per fi cial follicular in flam ma tion.

TREAT MENT
][78][79][80] Al though there are a num ber of re ports con cern ing differ ent types of med i cal man age ment with al ter ing com bina tions of var i ous drugs, in clud ing top i cal and/or systemic an ti bi ot ics for stage I-II dis ease, the ef fec tively of med i cal ap proach is still con tro ver sial [80][81][82][83] .The ini ti ated med i cal treat ment leads to de layed sur gi cal in ter ven tion hav ing been re served for stage II-III pa tients with ex tensive skin and soft-tis sue in volve ment.On the other hand, most sur geons be lieve that the sur gi cal ap proach via ex cision of the af fected tis sues is the only cu ra tive treat ment and early re fer ral for op er a tive re sec tion may limit the ex tent of this de bil i tat ing dis ease [80][81][82][83] Treat ment of HS can be ac com plished through med i cal or sur gi cal pro ce dures.The most rad i cal and to tally cu rative treat ment mo dal ity is ac cepted to be sur gery.In ci -sion and drain age, per formed in acute sit u a tions in var ious sur ger ies, are prob a bly the most com mon treat ments for HS pa tients, and may some times lead to tem po rary con trol of symp toms [83][84][85] .
Unroofing and exteriorization of the si nus tracts may be of value.Proper exteriorization in volves re moval of the ''roofs'' of si nus tracts, re moval of all gran u la tion tissue, which in some cases may be rather ex ten sive, and slow heal ing by sec ond ary in ten tion.It is spec u lated that op ti mal exteriorization is highly de pend ent on the skill and train ing of the sur geon, and that op ti mal re sults may be eas ier to ob tain with an ex ci sion.It is com mon to find large ar eas of skin un der mined with tracks run ning for long dis tances, but usu ally at the same depth.Unroofing all the fis tu lous tracts and ab scesses may be con sid ered to cre ate an ex ten sive open wound con sist ing of mul ti ple in ter con nect ing bridges of skin, which can make heal ing eas ier and faster [83][84][85] .
Sur gery for cu ra tive in tent re quires com plete ex ci sion of dis eased skin.Ex ci sion with pri mary clo sure may be per formed in se lected small wounds if it can be closed with out ten sion.This treat ment mo dal ity re sults in decreased mor bid ity, length of hos pi tal iza tion, post op er ative dis abil ity 86 .Oth ers have ad vo cated wide ex ci sion and heal ing by sec ond ary in ten tion.Balik 87 et al, re ported wide ex ci sion, (all of the grossly in volved apocrine bearing skin in the per i neal area should be ex cised full thickness into the un in volved gluteal fat) and sec ond ary in tention is good op tion for treat ment of HS (Fig ure 3).This pro ce dure does not re quire stoma.Balik et al, also concluded that the most im por tant com pli ca tion of HS is squamous cell car ci noma (Fig ure 4). 87,88Pa tients with large ar eas of ef fected by HS may re quire staged ex cision.The ex tent of ex ci sion should re main out side the anal verge as long as there is no ob vi ous in volve ment or his tory of anal ca nal in volve ment.If ex ci sion near the anal ca nal is nec es sary, it should be lim ited and staged in re gards of pre ven tion of anal stric ture.Pro longed heal ing is the main dis ad van tage of this method.These pa tients re quire daily dress ing and wound care to pre vent the contracture for ma tion.Re cently, vac uum as sisted clo sure (VAC) method seemed to de crease the wound heal ing pe riod and short ens the length of hos pi tal iza tion.The main dis ad van tages of the VAC are the cost and tech nical is sues 89 .The de vice can't be used at the level of perianal mar gin and anal verge.At these lev els ap pli cation of the de vice is ex tremely dif fi cult.At this point the other so lu tion for the wound heal ing is im me di ate or delayed thick ness skin graft ing af ter wide ex ci sions (Fig ure 5).Also cu ta ne ous or myocutaneous flaps can be of fered for wound heal ing as same as PS (Fig ure 6) [87][88][89][90] .

Br. 2
Tech ni cal Op tions in Treat ment of Pilonidal Si nus and Hidradenitis Suppurativa 99

FIGURE 3 .
FIGURE 3. SEC OND ARY HEAL ING OF WOUND AF TER WIDE EX CI -SION

FIGURE 4 .
FIGURE 4. QUAMOUS CELL CAR CI NOMA TO CON SIST OF HIDRADENITIS SUPPURATIVA

Br. 2
Tech ni cal Op tions in Treat ment of Pilonidal Si nus and Hidradenitis Suppurativa 101