GPAtlas🧭 When to suspect
Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the natal cleft, in which hair and debris become trapped in a midline pit and drive a foreign-body reaction with sinus formation. It is a disease of young adults – commoner in men, peaking at 15–30 years – and is rare before puberty and uncommon after 40.
Suspect it in a young adult with pain, swelling and redness at the top of the natal cleft, or with recurrent discomfort or intermittent discharge of pus or blood from a small midline opening (a sinus pit). The strongest risk factors are a sedentary occupation with prolonged sitting (e.g. driving), coarse or excess body hair, obesity, a deep natal cleft and a family history.
The key primary-care skill is to recognise which of four patterns the patient has – this drives management – and to distinguish pilonidal disease from perianal pathology, which sits in a different place and follows a different pathway.
| Presentation | Typical features | Action |
|---|---|---|
| Asymptomatic | Midline pit(s) ± small painless swelling; no infection | Conservative – hygiene and hair-removal advice; no surgery |
| Acute abscess | Painful, hot, fluctuant swelling; difficulty sitting | Incision and drainage (same day) |
| Chronic sinus | Persistent or intermittent discharge of pus/blood from a pit | Routine surgical referral for definitive treatment |
| Recurrent | Repeated abscesses or discharge after previous treatment | Surgical referral, with depilation to reduce recurrence |
Source: NICE
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