What is pilonidal disease?
Pronounced pie-low-NYE-dal
Pilonidal disease is a common condition of the skin and tissue at the top of the buttock crease (the natal cleft). Loose hairs and debris become trapped in small midline skin openings called pits, causing irritation, infection, and tunnels under the skin (sinus tracts). It is not dangerous, but it can be painful and tends to come back if not treated properly.
Although often called a pilonidal "cyst", most pilonidal problems are actually abscesses (infected pockets), not true cysts. This matters for treatment: the real source of the problem is the tiny midline pits where hair and bacteria get in — effective surgery focuses on eliminating those pits, not on removing a "sac".
Who gets it?
- Most common in teenagers and young adults (ages 15–30), though it can appear at any age; more common in men, but it affects women too — often at a younger age
- Risk factors: coarse or abundant body hair, prolonged sitting, friction, a deep natal cleft, being overweight, and smoking
- It can run in families, and it is far more common than most people realize — it's just rarely talked about
Common symptoms
- Pain or tenderness at the top of the buttock crease, especially with sitting
- A tender lump or swelling (an abscess when infected)
- Drainage of fluid, pus, or blood from small openings; sometimes an odour
- Some people have painless pits found incidentally — these often need no treatment
Common questions
Why did this happen to me? It's not your fault. Pilonidal disease results from a combination of hair, friction, and skin anatomy — not poor hygiene.
Is it contagious? No. You cannot catch it from, or give it to, anyone else.
Will it go away on its own? A small abscess may drain and settle for a while, but without treating the underlying pits most people have repeat flare-ups.
Will I need surgery? Not always. Some people manage with hair removal and self-care, but most people with recurrent symptoms benefit from at least a minimally invasive procedure. See the Treatments tab.
Treatment options
Treatment depends on whether you have an active infection, how many times it has come back, and the extent of the disease. Dr. Cowie will discuss which option fits your situation. Tap each option to learn more.
Conservative care & hair removal
For minimal symptoms, keeping the area clean and free of hair may control the disease. This includes regular shaving, depilatory creams, or laser hair removal (the most durable option, often recommended alongside any surgery to reduce recurrence), plus good hygiene and avoiding prolonged sitting where possible.
Incision & drainage (for abscess)
When an abscess forms, it is opened through a small incision — ideally just off the midline — to release the pus. This relieves pain quickly but treats the infection only, not the underlying pits, so definitive treatment may still be needed later.
Pit picking (Gips procedure)
The tiny midline pits are individually excised with small punches (a few millimetres each), and the sinus cavity is cleaned out through a small off-midline opening. Done under local anesthetic, with return to most activities within days. A small wick of packing is placed and removed in the office about 2 days later. Best for limited disease; recurrence is higher than flap surgery but the procedure can be repeated.
Endoscopic treatment (EPSiT)
A small camera (endoscope) is passed into the sinus through an existing opening. Hair and debris are removed under direct vision and the tract is cauterized from the inside. No large wound, quick recovery. Availability varies by centre.
Excision with open wound — not recommended in our practice
In this older approach, the entire sinus complex is cut out and the wound is left open to heal from the bottom up with dressing changes. Dr. Cowie does not recommend this operation. Healing is slow — commonly 6–12 weeks of daily wound care, sometimes longer — and despite that burden, recurrence rates remain higher than with modern off-midline procedures, because the healed scar still sits in the depth of the cleft. Wide midline excision with closed midline stitching is likewise not recommended, due to high rates of wound breakdown and recurrence.
If you have been offered this surgery elsewhere, or had it before and the disease returned, it is worth discussing the alternatives on this page.
Off-midline closure — Karydakis / Bascom cleft lift
The diseased tissue is removed and the wound is closed with a flap of healthy skin so that the final scar sits beside the midline rather than in the depth of the cleft. This flattens the cleft, keeping the area drier and hair-free — the key to preventing recurrence. Usually done as day surgery. A small drain is placed and removed in the office about 5 days later; wound healing typically takes 4–6 weeks.
Limberg (rhomboid) flap
For extensive or repeatedly recurrent disease, the diseased area is removed as a diamond shape and a matching flap of nearby healthy skin and fat is rotated in to fill the defect. This flattens the cleft completely. It is a larger operation with a bigger scar, but recurrence rates are low.
Comparing your options at a glance
| Procedure | Typical healing | Recurrence |
|---|---|---|
| Incision & drainage (abscess only) | 1–3 weeks | High — treats the infection, not the cause |
| Pit picking (Gips) / EPSiT | 2–4 weeks; back to activity in days | Moderate (~10–20%); repeatable |
| Cleft lift / off-midline flap | 4–6 weeks | Low (~2–10%) |
| Open excision — not recommended | 6–12 weeks of daily wound care | Moderate–high despite long healing |
| Midline excision, stitched closed — not recommended | 2–4 weeks if it heals; frequent breakdown | High (up to 40–50%) |
Ranges adapted from the Pilonidal Support Alliance (pilonidal.org) and published literature; outcomes vary with disease extent and individual factors.
After your surgery
Your first follow-up — and keeping the wound dry
Keep your wound dry until you are seen in the office for your first follow-up. No showers over the wound area and no baths or swimming until then.
- After pit picking (Gips): follow-up is typically 2 days after surgery, when the small wick of packing is removed
- After cleft lift: follow-up is typically 5 days after surgery, when the drain is removed
At that visit you will get instructions for washing and dressings from then on.
Typical recovery times
- Pit picking (Gips) / EPSiT: back to school or desk work in 1–3 days; small wounds heal in 2–4 weeks
- Incision & drainage: pain improves within days; wound heals over 2–4 weeks with dressings
- Cleft lift / flap surgery: take it easy the first 1–2 weeks; wound healing typically takes 4–6 weeks; avoid strenuous activity and cycling until cleared (~4–6 weeks)
Wound care
- Follow the specific instructions you were given at surgery — they take priority over this general advice
- Keep the wound dry until your first office follow-up (see above); after that, follow the washing and dressing plan given at your visit
- Some clear or blood-tinged drainage on the dressing is normal in the first days
Activity, sitting & driving
- Walk early and often — it helps healing
- Avoid prolonged sitting for the first 1–2 weeks; when you must sit, shift your weight or use a soft cushion (avoid ring/"donut" cushions after flap surgery unless advised)
- Do not drive until you can sit comfortably and are off sedating pain medication
- Avoid heavy lifting, cycling, rowing, and squats until cleared — usually 4–6 weeks after flap surgery
Pain control
- Most pain is well controlled with regular acetaminophen (Tylenol) plus ibuprofen (Advil) if you are able to take it
- If a stronger medication was prescribed, use it only for breakthrough pain and stop as soon as possible
- Constipation is common after surgery and opioids — drink fluids, eat fibre, and use a stool softener if needed
Preventing recurrence
- Keep the area hair-free once healed — laser hair removal is the most durable method; shaving or depilatory cream every 2–3 weeks is an alternative
- Keep the area clean and dry; avoid very prolonged sitting where possible
- Do not smoke — it is the single biggest modifiable risk for wound problems and recurrence
- Fever over 38.5 °C or chills
- Spreading redness, increasing pain, or foul-smelling discharge
- The wound edges opening up (for closed wounds)
- Bleeding that doesn't stop with 10–15 minutes of firm pressure