Evaluation of 60 Patients with Pilonidal Sinus Treated with Y O

Evaluation of 60 Patients with Pilonidal Sinus Treated with
Laser Epilation after Surgery
YASEMIN ORAM, MD, FERAYI KAHRAMAN,y YELDA KARINCAOG˘LU, MD,z
AND
ERKAN KOYUNCU, MD
BACKGROUND The surgical treatments for pilonidal sinus disease often result in recurrences, and the
patients risk requiring multiple surgical interventions.
OBJECTIVE
disease.
To evaluate the role of alexandrite laser hair removal after surgery in pilonidal sinus
METHODS Sixty patients who underwent surgical treatment of pilonidal sinus disease and were treated
with a 755-nm alexandrite laser after surgery between 1999 and 2007 were examined retrospectively. The
charts were reviewed, and the patients were interviewed on the telephone about their post-laser period
and recurrence. The laser parameters, patient history, and surgical details were recorded.
RESULTS The overall recurrence rate was 13.3%, after a mean follow-up period 7 standard error of the
mean of 4.8 7 0.3 years. The mean number of laser treatment was 2.7 7 0.1. Seventy-five percent of the
recurrences were detected after a follow-up period of 5 to 9 years. Fifty percent of the recurrent cases had
drainage and secondary intention before the laser epilation.
CONCLUSION Our results strongly suggest that laser hair removal after surgical interventions in
pilonidal sinus disease decreases the risk of recurrence over the long term.
The authors have indicated no significant interest with commercial supporters.
P
ilonidal sinus is a debilitating, painful, chronic
disease of the natal cleft that involves mainly the
sacrococcygeal region. The clinical presentation of
the disease varies from asymptomatic pits to painful
draining abscesses. The most common manifestation
of pilonidal disease is a painful fluctuant mass in the
sacrococcygeal region. Treatment options include
observation, antibiotics, drainage, and wide excision; surgical therapies often result in high rate of
recurrences, and the patients risk requiring repeated
surgical interventions.1–4 In recent years, reports of
laser epilation in the pilonidal sinus have shown
beneficial effect by decreasing the risk of recurrent
pilonidal sinus disease.5–11
In this study, we evaluated pilonidal sinus cases
treated with alexandrite laser epilation after surgical
interventions.
METHODS
Seventy-eight patients with surgically treated pilonidal sinus were treated with alexandrite laser for hair
removal between 1999 and 2007 in a private dermatology unit. In June 2008, the patients were interviewed by telephone about the postlaser period.
Exclusion criteria included cases with inadequate
information and follow-up and patients who had
only one laser treatment. Sixty of the 78 patients
were identified and included in the study.
The charts were reviewed, and age, sex, family history of pilonidal sinus disease, date of surgery, surgery type, number of laser treatments, laser energy
parameters, and whether the pilonidal sinus disease
was primary or recurrent were recorded. The laser
system protocols and patient characteristics are
Dermatology Unit, American Hospital, I˙stanbul, Turkey; yMedical Technician, Private Practice, I˙stanbul, Turkey;
z
Department of Dermatology, Inonu University, Malatya, Turkey
& 2009 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2010;36:88–91 DOI: 10.1111/j.1524-4725.2009.01387.x
88
ORAM ET AL
TABLE 1. Laser Protocol Specifics
Laser
System
Wavelength
(nm)
Pulse
Duration
(ms)
Fluence
(J/cm2)
Spot Size
(mm)
Treatments,
n
Post-Surgical
Time Interval
(Months)
Patients,
n
Cynosure Apogee 5500
Candela
Gentlase
755
3
20–27
12–15
2–4
1–2
19
755
3
14–20
18
2–5
1–12
41
shown in Tables 1 and 2. During the telephone
interview, patients were asked whether they
experienced any recurrence after the laser
treatment.
A 755-nm alexandrite laser (Apogee 5500, Cynosure
Inc., Westford, MA, and Gentlelase, Candela Laser
Corp., Wayland, MA) was used. Two of the authors
(YO, FK) treated the patients. The number of
epilation treatments ranged from two to five performed at 6- to 8-week intervals. The first laser
treatment was conducted as early as 4 weeks to as
late as 1 year after the surgery. Laser treatments were
performed after healing from the surgery was
completed. Because the epilation area is non-sun
exposed and suitable for higher energies, the
fluence and the spot size used were the maximum
according to the device guide. The epilation area
was not confined to the surgery area but
extended to the buttocks, perianal region, and
lower back of the patients with large flap
reconstruction.
RESULTS
The age of the patients ranged between 12 and 40,
with a mean 7 standard error of the mean of
22.5 7 0.8. Fifty-one of the 60 cases were male
(85%), and nine were female (15%). Most (91.7%)
of the patients had primary pilonidal disease,
whereas 8.3% had recurrent pilonidal disease.
Twenty-four patients (40%) had a positive family
history of pilonidal sinus disease.
Forty-one of the 60 cases (67.2%) had excision
and flap reconstruction (E 1 F), 13 (21.7%) had
incision and drainage (I 1 D), four (6.7%) had
excision and primary closure (E 1 P), and two
(3.33%) had excision and secondary intention
healing (E 1 S). The mean number of laser
treatments was 2.7 7 0.1; all eight recurrent cases
had two treatment sessions.
The overall recurrence rate was 13.3%, after a mean
follow-up period of 4.8 7 0.3 years. All recurrent
cases had primary pilonidal sinus disease.
TABLE 2. Patient Characteristics
Previous Surgery
Laser
System
Cynosure
Apogee
5500
Candela
Gentlase
Total
F:M
Age (Mean 7 Standard Error of the
Mean)
Fitzpatrick
Skin Type
Excision 1
Flap
1:18
23.1 7 1.3
III–IV
11
8:33
22.2 7 1.1
III–IV
60
22.5 7 0.8
III–IV
Excision 1
Primary
Closure
Excision 1
Secondary
Intention
7
2
2
30
6
2
F
41
13
4
2
Incision 1
Drainage
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PILONIDAL SINUS
Twenty-nine cases (48.3%) had a follow-up period
of less than 5 years, and 31 cases (51.7%) had
more than 5 years of follow-up. Telephone
interviews revealed that six of the eight (75%)
recurrences occured 5 to 7 years after laser epilation
treatments and two (25%) were detected during
the first 2 years of the postlaser period. Three of
41 cases in the E 1 F group (7.3%), four of 13
(30.8%) in the I 1 D group, and one of four (25%)
in the E 1 P group had recurrences. Of the eight
cases with a recurrence after laser epilation, four
(50%) had I 1 D, three (37.5%) had E 1 F, and one
(12.5%) had E 1 P.
DISCUSSION
Pilonidal disease is observed most commonly in
young adults, with an incidence of 26 per 100,000
population. Men are affected twice as frequently.4
The origin of pilonidal sinus has been a subject of
interest for many years. In the 1950s, it was thought
to be of congenital origin, involving the remnant
of the medullary canal and the infolding of the
surface epithelium or a faulty coalescence of the
cutaneous covering in the early embryonic stage,1,2
but most authors now believe that the majority of
pilonidal disease cases are acquired and the result of
a foreign body response to entrapped hair.1,2,5 After
the onset of puberty, sex hormones affect the
pilosebaceous glands, and the hair follicles become
distended with keratin. As a result, a folliculitis is
created, which produces edema and follicular
occlusion. The infected follicle extends and ruptures
into the subcutaneous tissue, forming a pilonidal
abscess. This results in a sinus tract that leads to a
deep subcutaneous cavity. The laterally communicating sinus overlying the sacrum is created as the
pilonidal abscess spontaneously drains to the skin
surface.1 Loose hairs are drilled, propelled, and
sucked into the pilonidal sinus by friction and
movement of the buttocks whenever the patient
stands and sits. This trapped hair stimulates a foreign body reaction and infection.1–3 Excess hair in
and around the gluteal cleft increases the risk of the
occurrence of the disease, and the frequency and
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D E R M AT O L O G I C S U R G E RY
severity of recurrences are directly related to the
density of the hair present on the buttocks.5 Longlasting or permanent hair removal in the gluteal area
in pilonidal sinus disease would eliminate the hairs
and decrease the risk of recurrent disease.9,11
The recurrence rate of pilonidal sinus varies depending on the treatment method and the follow-up
period of the study.1–4,12,13 Recurrent pilonidal
disease is observed most commonly after the incision
and drainage of a pilonidal abscess in which the
pilonidal sinus has not been excised and is still
present after the abscess cavity heals.13 In this setting, the base of the unhealed surgical wound is
believed to become filled with granulation tissue,
hair, and skin debris, which acts as a nidus for the
ongoing foreign body reaction that takes place to
create the recurrent and chronic pilonidal disease. In
accordance with this theory, in our study, even with
laser epilation, 50% of the patients who developed
recurrence in the follow-up period had been treated
using I 1 D. Recurrence rates after excision and
primary closure may be as high as 38%, although the
healing period has been shorter than with E 1 S.1,13
In the present study, the recurrence rate in the E 1 P
group decreased to 25% with additional laser
epilation. The E 1 F has been shown to provide the
best results regarding recurrence risk and healing
time. Our study also confirmed that only three of the
41 (7.3%) patients who underwent E 1 F before
laser epilation developed recurrence.
The recent literature consists of reports on the benefits of laser epilation in pilonidal sinus disease.
Benedetto and Lewis5 reported two patients with
recalcitrant pilonidal sinus disease treated with an
800-nm diode laser, resulting in long-term relief.
Similarly, Lavelle and colleagues6 presented a case of
pilonidal sinus disease. They treated the surgical scar
site five times with ruby laser for epilation and did
not observe recurrence in 6 months. Conroy and
colleagues7 reviewed 14 patients who underwent
laser hair removal after pilonidal sinus surgery. The
mean number of treatments was 3.9, and none of the
patients had developed recurrent disease at 1-year
ORAM ET AL
follow-up. They suggested that laser hair depilation
and the personal hygiene of the patient were useful
in preventing recurrent pilonidal sinus disease.
Schulze and colleagues8 reported that 19 of 23
patients who had laser epilation after surgical
interventions and remained in follow-up did not
have recurrence or need further surgery. The
inadequate follow-up period and small number of
patients in these studies make it difficult to derive
firm conclusions, but our results and the literature
support the beneficial effect of laser epilation as
primary treatment or as an adjunct to surgery, even
with a small number of laser treatments. All eight
recurrent cases in our study had only two laser
treatments. Finer and sparser hair regrowth after
two laser treatments might explain the recurrences in
those cases. Although it has been postulated that a
few laser treatments appear to be enough to prevent
recurrent pilonidal sinus disease,10 we believe that
multiple treatments are needed to remove the maximum number of hairs to achieve better clearance
and low risk of recurrence.
After telephone interviews with 205 patients, Doll
and colleagues12 reported the long-term recurrence
rate as 22% after the first pilonidal sinus disease
surgery and suggested that the follow-up should be 5
years or longer, because the majority of recurrences
occur during the late postoperative interval. In our
study, recurrences were also recorded in telephone
interviews. Apparently, telephone follow-up in both
studies resulted in less reliable data than with direct
examination, although we believe that the low recurrence rate in our study (13.3%) is probably due to the
laser epilation treatments after surgery. In addition, we
agree with the necessity of longer follow-up of the
patients, because 75% of the recurrences were detected a minimum of 5 years after the laser treatment.
The main goals of the management of pilonidal sinus
disease should be determining the ideal medical or
surgical treatment, which includes minimal inconvenience to the patient, a short period of hospitalization, and most importantly, a low risk of recurrence.
In this study, the recurrence rates for different
surgical interventions were found to be comparable
with the results of previous studies, but our
results strongly suggest that laser hair removal
after surgical interventions in pilonidal sinus disease
decreases the risk of recurrence in the long term.
Laser epilation is simple and quick, without any
complications. We recommend laser epilation
to every patient with pilonidal sinus disease as an
adjunct treatment after the surgical intervention to
prevent further surgery.
References
1. Nivatvongs S. Pilonidal disease. In: Gordon PH, Nivatvongs S,
editors. Principles and Practice of Surgery for the Colon, Rectum,
and Anus. New York: Informa Health Care USA Inc.; 2007.
p. 235–46.
2. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am
2002;82:1169–85.
3. da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon Rectum 2000;43:1146–56.
4. McCallum IJD, King PM, Bruce J. Healing by primary closure
versus open healing after surgery for pilonidal sinus: systematic
review and meta-analysis. BMJ 2008;336:868–71.
5. Benedetto AV, Lewis AT. Pilonidal sinus disease treated by
depilation using an 800 nm diode laser and review of the literature. Dermatol Surg 2005;31:587–91.
6. Lavelle M, Jafri Z, Town G. Recurrent pilonidal sinus treated with
epilation using a ruby laser. J Cosmet Laser Ther 2002;4:45–7.
7. Conroy FJ, Kandamany N, Mahaffey PJ. Laser depilation and
hygiene: preventing recurrent pilonidal sinus disease. J Plast Reconstr Aesthet Surg 2008;61:1069–72.
8. Schulze SM, Patel N, Hertzog D, Fares LG. Treatment of pilonidal
disease with laser epilation. Am Surg 2006;72:534–7.
9. Sadick NS, Yee-Levin J. Laser and light treatments for pilonidal
cysts. Cutis 2006;78:125–8.
10. Downs AMR, Palmer J. Laser hair removal for recurrent pilonidal
sinus disease. J Cosmet Laser Ther 2002;4:91.
11. Landa N, Aller O, Landa-Gundin N, et al. Successful treatment of
recurrent pilonidal sinus with laser epilation. Dermatol Surg
2005;31:726–8.
12. Doll D, Krueger CM, Schrank S, et al. Timeline of recurrence after
primary and secondary pilonidal sinus surgery. Dis Colon Rectum
2007;50:1928–34.
13. Clothier PR, Haywood IR. The natural history of the post anal
(pilonidal) sinus. Ann Royal Coll Surg Engl 1984;66:201–3.
Address correspondence and reprint requests to: Yasemin
Oram, MD, Amerikan Hastanesi, Dermatoloji Bo¨lu¨mu¨,
Gu¨zelbahc¸e sokak No. 20, Ni ¸santa ¸si, I˙stanbul, Tu¨rkiye, or
e-mail: [email protected]
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