What does a pilonidal cyst initially look like?

Pilonidal Cyst Initial Appearance

A pilonidal cyst initially appears as a small, firm, pink nodular lesion near the gluteal cleft, often with a visible pit or opening that may contain hair. 1

Clinical Characteristics of Early Pilonidal Cysts

Pilonidal cysts typically present with the following initial features:

• Small, firm, pink nodular lesion in the sacrococcygeal region (usually within the gluteal cleft)
• Often asymptomatic in early stages before complications develop
• May have one or more visible pits or openings in the midline of the gluteal cleft
• Visible hair may protrude from these openings
• Usually located within 1 cm of the coccyx within the gluteal cleft 2
• Often only visible when the buttock cheeks are separated for examination

Dermoscopic Features

When examined with dermoscopy, early pilonidal cysts typically show:

• Pink homogenous background
• Central yellowish or white structureless areas
• Peripherally arranged blood vessels (dotted, glomerular, or hairpin pattern)
• White reticular lines may be present 1
• Hair shafts may be visible within the opening

Disease Progression

If left untreated, the initial pilonidal cyst may progress to:

1. Acute abscess: Becomes painful, swollen, and erythematous with possible purulent discharge
2. Chronic draining sinus: Develops intermittent discharge from one or more openings
3. Multiple tracts: Formation of additional sinus tracts in the surrounding area

Differential Diagnosis

It's important to distinguish pilonidal cysts from:

• Coccygeal dimples (normal variant): Located at or below an imaginary line between the tops of the gluteal cleft forks 2
• Epidermal cysts: Have punctum and ivory-white background on dermoscopy 1
• Dermatologic sinuses: Different vascular pattern on dermoscopy
• Hidradenitis suppurativa: More widespread distribution, not limited to gluteal cleft

Important Clinical Considerations

• Pilonidal disease affects young adults, typically between ages 15-30
• Male predominance with a male-to-female ratio of 3-4:1 1
• Risk factors include obesity, sedentary lifestyle, excessive body hair, and poor hygiene
• Early diagnosis is important as malignant degeneration can occur (though rare at 0.1%) 3

Management Approach

For early, asymptomatic pilonidal cysts:

• Regular hygiene and hair removal in the affected area
• Avoid prolonged sitting
• Consider surgical referral even for asymptomatic lesions to prevent complications

For symptomatic or infected pilonidal cysts:

• Surgical intervention is typically required
• Acute abscesses require drainage, preferably with off-midline incision 4
• Definitive treatment involves excision of the cyst and sinus tracts

Early recognition and appropriate management of pilonidal cysts can prevent progression to more complicated disease requiring extensive surgical intervention.