DRHOOK- Pilonidal cysts: Cheeky friction leads to trouble

the handsome doctor John Hong

"Crack is whack," according to once diva superstar Whitney Houston. Some other cracks are really bad: crack in your windshield, crack in your fine china, step on a crack break your mother's back– 

Other cracks are good: crack a smile, crack up at a good joke, cheese and crack...ers.

What about the gluteal cleft, otherwise known as a person's crack?

Pilonidal cysts are pretty common in adults, especially between the ages of 20-30. These cysts or abscesses are found in the gluteal cleft, which is the crease formed between the buttocks. I think we are all very aware of the gluteal cleft now because many people flash a "rear end smile" when they bend over to pick up something. Pants just aren't what they used to be! (Also, Americans are developing larger derrieres than J. Lo.)

The classic pilonidal cyst is at the top of the gluteal cleft (aka the natal cleft) by the tailbone. This cyst might be a result of the skin layer and deeper layers not fully separating in an embryo in mum's womb. The pilonidal cyst might actually contain hair (and you thought only cats had hairballs). This type of pilonidal cyst usually is painless and not a problem.

Other pilonidal cysts can form further down, heading towards the anus. These cysts might be a result of friction: butt cheek meeting other butt check. Perhaps hair follicles grow inward to cause the cysts or abscesses. Folks with tinea cruris ("jock itch") can have the fungal infection in both the groin/inner thigh region and/or in the gluteal cleft. This fungal infection can break down the skin, letting bacteria enter to cause an abscess. 

Your kids might be a pain in the butt, but an acute pilonidal abscess really hurts! Swelling and redness around the area make it tender to touch. 

However, in most people it's hard to see the gluteal cleft, so a trip to the doctor usually takes priority over grocery shopping. (I don't know why folks in relationships don't ask their other half to check it out. Maybe it's unromantic or embarrassing, but still I think worthwhile.) If a person develops a fever with the pain, then the infection is really, really b-a-d.

Chronic pilonidal disease is no fun. There can be one or more sinuses connecting to the cyst– like Luray Caverns. Holy bat cave! Pus or just mucus can constantly drain out of a pilonidal cyst. Some people don't like to have them treated because they worry about the pain after surgery, about embarrassment, or a previous surgery failed. The problem beside infections and pain is that a neglected pilonidal cyst can lead to squamous cell carcinoma (i.e. skin cancer). 

Do you own a donut-hole cushion? I have a Brookstone foam seat cushion that looks like a "U" that reduces pressure on the coccyx and therefore the gluteal cleft. Sitting down too long might be a cause of pilonidal cysts because many WWII servicemen were hospitalized for them. Perhaps they formed from the rough riding in jeeps, tanks, and trucks. Yee haw!

An abscess around/on the anus or a fistula (like a tunnel) from the butt to the rectum is a bad situation that requires general surgery. Removing the hair in the doctor's office can sometimes treat mild pilonidal disease. An abscess has to be drained because antibiotics can't enter the cavity to clean things up. 

I refer everyone to a surgeon for this because just cutting it open and draining it might not be enough. Plus, it takes on average five weeks to heal. 

Crack might be whack, but a pilonidal cyst/abscess can really whack your butt.


Dr. Hook cracks a joke or two, but he's a renowned physician with an interesting website, drjohnhong.com. Email him with your questions.