Is a tract required for the diagnosis of a pilonidal cyst?

Diagnosis of Pilonidal Cyst

A tract is not required for the diagnosis of a pilonidal cyst. 1 While pilonidal cysts often have an underlying tract, the diagnosis is based on clinical presentation rather than the presence of a specific anatomical feature.

Clinical Diagnostic Criteria

Pilonidal cysts are diagnosed primarily through clinical assessment, with the following key features:

• Pain and tenderness in the sacrococcygeal region
• Swelling and redness over the affected area
• Drainage of purulent material if infected
• Possible fever if systemic infection is present
• Pruritus ani in some cases 1

Anatomical Considerations

While many pilonidal cysts do have an underlying tract of epithelial and fibrous tissue that pierces the skin 2, this is not a mandatory diagnostic criterion. The term "pilonidal" literally means "nest of hair," and these lesions typically contain hair follicles with surrounding inflammatory reaction 3, 4.

Diagnostic Approach

The diagnosis is primarily clinical and usually straightforward 5. Key elements include:

• Visual inspection of the sacrococcygeal region (most common location)
• Identification of midline pits or openings in the natal cleft
• Assessment for signs of acute inflammation or chronic discharge
• Evaluation for the presence of hair within the lesion (though not always visible)

Imaging in Complex Cases

• MRI may be used to identify the extent of disease, particularly in complex or recurrent cases 1
• However, routine imaging is not necessary for initial diagnosis of typical presentations

Differential Diagnosis

It's important to distinguish pilonidal disease from other conditions:

• Perianal abscess or fistula
• Hidradenitis suppurativa
• Infected sebaceous cyst
• Furuncle or carbuncle
• Dermoid cyst

Atypical Locations

While most commonly found in the sacrococcygeal region, pilonidal cysts have been reported in other locations:

• Periclitoral region 3, 4
• Scalp 6
• Interdigital spaces
• Umbilicus

Management Considerations

Once diagnosed, treatment typically involves:

• Incision and drainage for inflamed or infected cysts
• Appropriate wound care
• Consideration of definitive surgical management for recurrent cases 1

Common Pitfalls in Diagnosis

• Mistaking a simple abscess for a pilonidal cyst
• Failing to recognize atypical presentations in unusual locations
• Overlooking the need for complete excision in chronic or recurrent cases
• Confusing a pilonidal cyst with a congenital dimple or sinus tract (which may have different implications) 2

Remember that while the presence of a tract is common in pilonidal disease, it is the clinical presentation and identification of hair-containing inflammatory lesion that establishes the diagnosis, not the specific anatomical feature of a tract.