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"Pilonidal" refers to conditions that occur just above the crease in the buttocks. A pilonidal cyst is probably self-explanatory, except for the fact is often contains hair. A pilonidal dimple is a "crack above your crack." Pilonidal sinuses are "cysts on steroids," larger lesions that can become swollen and painful as they drain.

Pilonidal cysts are primarily a disease of males, who are two to four times more likely to develop them than females. Most of the time the cysts appear at about the age of 20, which is also the same time as some people get cystic acne. They are very rare after the age of 45. Pilonidal cysts begin as a hair that grows backward into a pore, but the pore expands with white blood cells and skin debris. Usually they occur in the "crack" 4 to 5 cm (2 to 3 inches) behind the anus. They can occur higher. These cysts will itch, bleed, and sometimes hurt. Symptoms tend to be worse at night.

Usually pilonidal cysts develop at a point of irritation, under a tight belt, tight jeans, sports gear, or a uniform. They can also occur on the buttocks of people who spend most of their time sitting. They don't always occur over the buttocks. Young people who shear sheep, for example, can get them just about anywhere on the body. 

Healing a pilonidal cyst or sinus requires opening it, removing the hair and debris, and allowing the skin to grow back over it. This isn't a do-if-yourself project. You need to see a doctor. The doctor will make an incision up and down over the cyst and remove the "pus" and hair inside. Then the area will be packed with sterile gauze and you will be asked to come back to the doctor's office or the ER (a surprising number of these procedures occur in the emergency room) in a couple of days for the wound to be dressed again. Relieve pain by taking sitz baths, sitting in warm water, and avoiding tight clothing.

However, there are things you can do to keep pilonidal cysts and sinuses from coming back.

  • Shaving the area with a safety razor once a week will keep new cysts from forming. This isn't something you should attempt to do for yourself, since self-shaving of the butt crack is sure to result in nicks, cuts, scrapes, and rashes, sometimes severe, itchy rashes.
  • Lanolin reduces friction on the skin but increases inflammation. Don't apply lanolin directly to a pilonidal cyst.
  • Laser hair removal may slow down certain cases, but it's not a permanent cure. It's actually possible for hair to come back even after laser treatment. This is also something you can't do for yourself, although an aesthetician who is licensed to do laser hair removal can take care of the problem, as well as a doctor. Most people need to have the skin numbed before the procedure.
  • After a surgical procedure for pilonidal cyst, tea tree oil creams applied to the surgical site can reduce the risk of infection. However, if severe post-surgical inflammation or a bad odor occurs, you need to see a doctor right away.
  • If you already have a pilonidal cyst, shaving and laser treatments won't treat it. They just keep it from coming back once it has been treated by your doctor.
  • If lancing a pimple on your buttocks doesn't work for you, your doctor may offer photodynamic therapy. The doctor applies a cream of a medication called methyl aminolaevulinate (in the United States, its trade name is Metvix) and then shines a red light lamp of affected skin. Each treatment takes three hours. There are nine treatments over 15 days. Since this use of Metvix is off-label, insurance usually won't pay for it. However, the treatment has a good success rate, and usually relieves symptoms for up to a year. This treatment is also used for a related condition called hidradenitis suppurativa.

About 40 percent of pilonidal cysts eventually come back no matter what you do. Second surgeries are common, and in rare cases, the cyst can progress to squamous cell carcinoma. Even if the cysts do not come back, they are something your doctor should be aware of so you can be checked for signs of this treatable form of skin cancer.

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