Cysts in the gluteal cleft cause pain and embarrassment – and often recur. Here’s the evidence on which treatments and techniques have the best outcomes for kids with this common condition.
I'm going to talk about Palin Idol disease and my partner Willie moses, who is our newest partner who just started uh less than a week ago, delighted to get him to talk about that in a little bit. Um at the end of my talk um is uh pilot Idol disease and pilot Idol disease uh is um just a very insidious disease. It can be very debilitating. And I think our treatments for this historically have not been that great, but I think that there's been a lot of improvement. These are patients that often need multiple clinic visits, multiple procedures. And I think that the big shift has been to doing things as minimally invasive as possible initially because that seems to work in the bulk of cases. Uh It's pilo means hair and nights means nest and uh this uh really the inciting event is a combination of trauma to the area um and penetration of hair into the subcutaneous tissue with granule ation reaction. Uh It used to be called jeep drivers or jeep seat disease because young G. I. S. Uh in in the mid century, mid part of the last century uh would often get this disease because of repeated trauma to the Kochs eagle area and also probably because of their age. Uh uh particularly Hirsute patients would frequently get this and again being not so close to extensive medical treatment. This was obvious, oftentimes very debilitating. The spectrum of the disease ranges from asymptomatic cysts to sinuses deep abscesses. In fact, I just drained an abscess today and then fistula. So we we used to call it pie, not assist, but I think the term pilot cattle disease is actually much more appropriate. So this happens pretty commonly and one in about 100 and 50 to 1 in a couple of 1000. Uh There's a 4 to 1 male predominance for adults. Gender prevalence in Children may be about the same. In fact, it might be more common in in females more common in whites and caucasians. And it most commonly affects teens and young adults. Often occupations that require sitting are often uh more um affected and as I had mentioned, history of trauma to the sacrum and coccyx. So you can imagine that this is really uh you know, kids that are sitting in classes often there um uh they're very prone to it, so again, it's more common into her suit patients. Uh and the hair follicles is all the pediatricians know, become distended with carrot and after puberty. And I often say to the parents, this is like uh acne or is it uh in your gluteal cleft where you're a pilot idol area, your pre sequel area. And that's really how I think of it as almost like acne. And then the infected follicles may rupture or they may burrow deeper and form cysts or sinuses or fistula. And uh if you have a hair within these sister sinuses or officials, uh it will prevent healing. And often when you uh look at these sinuses or open up a sister and abscess, you'll pull out an amazing amount of hair from these. And once you do this you're you can imagine how this wouldn't heal. And the gluteal cleft is the site of the disease. Or as the kids like to say the butt crack. And uh it's not surprising because that area is close to the anus, there's a high bacterial account, it's not smooth, it's sort of got a crease in it. It's a hard area to keep clean, teenagers often sweat. And so all of that just makes for a difficult area to uh to keep clean And once problems develop it's hard to uh to fix it. So here's what it sometimes looks like. As you see this picture over here on the left, you'll see these little holes develop. The anus would be over to the screen right, and the upper back would be over to the screen left. And this is the gluteal cleft. You can see this patient has some here, not particularly harry. Uh And these all if you when I put a probe in this, this all connects underneath the skin. Over here on the uh right side of the screen, this is very much like the one that I saw today. Uh And um you can see that there's sarah thema, there's not a a sinus tractor and opening. Although if you look in the gluteal club, you might see some pinpoint openings lower down. But this is an abscess that's developing underneath the skin uh and this needs really uh incision and drainage before we do anything else. So again if you have an acute abscess then the treatment is incision and drainage and probably leaving some sort of drain in for some period of time as well as probably antibiotics. The use of antibiotics I think is not universally espoused uh but I think most people would use it if there's just inflammation and no uh no discrete abscess that I think antibiotics alone is reasonable. Sometimes an ultrasound can help delineate the two because sometimes the absences are deep enough that it hasn't really come to a head and there isn't really fluctuates there. Um When you have chronic cysts or sinuses or fistulas then initially but without a discrete abscess, then we usually start with non operative therapy. And this includes removal of hair. And this can be done either by shaving the area, um Other depilatory uh efforts. Or we have one of our uh at UCSF several of our dermatologists will do laser hair removal on them. Think that there's other people out in the community that do laser hair removal as well. And then particularly with the ones that have fistulas and sinuses. We recommend at least once a day but preferably twice a day, showers and sits baths to keep the area clean. Um And then if uh we have still persistent disease um then uh we recommend minimally invasive therapy. And if minimally invasive therapy several times and I'll go into what that is. Doesn't work. Then we'll talk about excision. And there have been advances in the bigger surgical excision as well. Okay um So um data. We all want data. And um when we talk about uh excision of the whole wound, which is Really what what I did when I was in training, when I started my surgical training 30 years ago, um uh every time we would see one of these patients, we would all just get, you know, very sort of uh sanguine about it because we knew that there was a high recurrence rate. And for many years the debate was we excise the area of the pilot idol disease in these patients that had multiple recurrences. And then would we uh leave the wound open? Or were we close the wound? And really, that was the debate that the surgeons had for many, many years when that was really are only options. And um, overall, there was less recurrence when we left the wounds open, but we're talking about, you know, Quite a large defect, you know, oftentimes like maybe 12 x six cm in kids that are trying to go to school. Uh, so although there were less recurrences and you know, we're still talking even with open wounds sometimes 30, 40, 50% recurrence of pollen Otto disease. It healed faster after we close the defect. Uh, and when you look at lots of different series, wound recurrence rates were varied widely from like 10% to 80%. Uh, so, um, the Cochrane Library, um, there was an analysis from the Cochrane Library that did a meta analysis and there was found to be no benefit to an open wound really. The major advance came from looking at doing midline versus non midline closures. So for many, many years, what we do is we'd make an ellipse around the gluteal cleft to include all the diseased area. We get down to the precinct wolf ASHA, and then we would close the wounded midline. What some surgeons identified was that if we close the wound, not in the midline but created a little flap and closed it off of midline. Uh that that seemed to decrease recurrences and uh in fact uh there have been multiple series to show that the incidence of um recurrences is far decreased when you do non midline closures and in fact they have better quality of life as well. So when we talk about recurrence, it, in fact is hard to compare different techniques. Um uh but as I have stated that non midline closures of and there's a variety of different ones seem to have lower recurrence. A little bit of wound separation is common because especially when we create these flaps, its under a little bit of tension. So there's a little bit of wound separation, but that is not the same as having a complete wounded his since uh and then having a recurrence of the disease. Um And really, you know what you call recurrence is sort of dependent on the point of view, is a little bit of wound separation recurrence or is it um you know uh sort of a full blown cyst. Again, it also depends on the length of follow up. Uh so uh in one large analysis meta analysis of almost 90,000 patients in 2018. If you follow them up for for a year, there's only a 2% recurrence, but if you follow them up for um 240 months, which is obviously a very very long time, As many as 60% may have recurrence. Uh So um uh you know um really a lot of the recurrences, depending on your point of view. So getting back to a non operative therapy which is what we would use first. Again if there is an abscess, then drain the abscess to get rid of the initial acute problem and it often hurts. It's often very painful especially when they try to sit, remove all the hair in the gluteal area as well as on the buttocks. Um Consider antibiotics, although I said I had mentioned that um it's not completely um uh espoused that antibiotics are helpful for acute infections and then shave the area. Or consider laser hair removal, avoid trauma to the sacrum and coccyx because that can be an exciting event. And then frequent showers and sits baths and again the recurrence rate here is still pretty high. It's you know, I would say About 30, 40 50%. Um So uh despite uh initial non operative therapy, uh many of these patients will go on to recur what what I think has really been, the game changer has been minimally invasive surgery and uh some people could refer to it as the gibbs procedure picnicking. Um But really what one does is we excise the sinus tracts because you have these epithelial is sinus tracts that go into the uh common sort of cyst deeper down. Then often times when we do this and we get into this um really this cave underneath the skin, I'm just shocked. That will play out clumps of hair. And you can imagine how this would just never heal. Then we debris the deeper tissue because a lot of this tissue is chronically infected. D vitalized. It's just nasty donkey tissue. And so we just scoop this tissue out, we irrigate uh sometimes we use peroxide. But I think really the most important thing is exciting, excising these epithelial is sinus tracts. because over time they become so epithelial is there like a piercing and they'll never completely close up. So we were excised that epithelial is tissue. Get rid of the hair, Get rid of the vitalized tissue and amazingly. Uh in most cases uh even after non operative therapy has failed this usually works. Some people are advocating using a scope to go in there and look around and pick away at some d vitalized tissue. Really that hasn't really proven to be that helpful fiber and glue to try to help everything stick together hasn't really been helpful. I do feel like these patients need to be closely monitored and we see these patients pretty often and continue the other aspects of non operative therapy which is keeping the hair out shaving their laser depilatory twice a day sits baths and or showers as well. Um Sometimes after either I. N. D. And drainage or pit picking. Sometimes we leave drains in for a period of time to allow these areas to stay open to let everything adequately drain out using this the best cases show Reports rates of about 10%. Some still have recurrence rates of about 50%. Um uh we found probably about 2030% recurrence rate But this is a 30 minute operation. And the patients have basically they can just go back to school with no disability really at all. When you get to the non midline closures there's a variety of techniques which again all show that they're superior of midline closure because when you do the midline closure you still have that incision down in the gluteal cleft and it's deep. Hard to keep clean it's under tension. Uh But when you move it over to the side it's more on the buttock. And that incision is flat. Uh the recurrence rate really. When we used to talk to patients about midline closures, we're talking consistently about 50% recurrence rates and now I quote them less than 10% and I think really less than 5%. The most common operation that's done is the gluteal cleft lip or the basque home procedure. And what we do is uh as you can see in this uh image, we excise the skin overlying the area, will get rid of all the gunky tissue. But then we create flaps including in fairly all the way down to the anus and then we move the skin from one side over to the other and then we have this flat incision over on the buttock and in fact it flattens out the gluteal cleft as well. And since I've adopted doing this procedure about six years ago, you know I used to be very sort of um uh sanguine about recurrence rates and now um really um uh even when the minimally invasive procedure doesn't work Uh you know I quote them less than 10% recurrence rate, which is great. Now having said that this is a big operation, it's hard for kids to sit for several weeks to a month. Uh And they have to be very careful because if the skin and underlying tissue comes apart then that can be problematic. Um One of the things that sometimes for the most difficult cases that we use for multiple recurrence rates despite all of these advances, is using a wound back. So we have this big open wound, we used to just leave this open but putting a wound back over this actually facilitates the closure of this incision uh and we'll close much quicker than if you just left it open with wet to dry dressing. So that's something that we will use rarely but can be effect. So here's the treatment algorithm. And a couple of years ago our National Organization apps had this uh consensus meeting. It was amazing that everybody kind of agreed. So non operative management which includes hygiene, hair removal and avoiding trauma if that doesn't work, then go to this minimally invasive pit picking procedure that I talked about while continuing non operative therapy. If that doesn't work, then go to non midline closure, continuing to do all these things. And if that doesn't work with recurrences despite non midline closure, then you can consider wound vac therapy. And so the red line is uh treatment failure. Now if you I would advocate for doing the minimally invasive procedure at least two or three times, sometimes four or five times because again, this is so minimally invasive and so quick and uh that uh I think it's the difference between doing this procedure as far as missing school and pain and debilitation is much less than from doing the bigger excision procedure. So finally I just wanted to end with our team. Then I'll take questions some of our team, I'm sure many of you know, and our friends with and have referred many patients, but our most senior surgeons who are just iconic surgeons and have contributed so much to our community uh dr bets over here and doctor do have been uh just icons with uh many of Children's Hospital Oakland and are in fact both one uh the uh um the bronze Bambina Beano Award including dr do just one that this past year dr kim who you just met who is really a world leader in the treatment of chest wall deformities. Dr chris Newton, who's our trauma director and peri operative medical director in the uh many of Children's Hospital, Oakland Dr Jensen, who recruited a year and a half ago from Children's Hospital, Los Angeles and both Dr Newton and Dr Jensen are both also boarded in um uh trauma critical care. Dr willie moses who just delighted dr moses I've known since he was a medical student and resident. Uh and um uh just finished his training down at C. H. L. A. Is coming back to do the full range of uh pediatric surgical care with our partners in the East Bay, but will focus primarily on pediatric surgical oncology. So he was mentored thereby, Dr kim and Dr Stein, who are leaders in surgical oncology and Children. And dr Bettes, excuse me, Dr moses gonna be our lead surgical oncologist um and then over in the West Bay uh here you see a picture of me, Dr tippy Mackenzie, who also is does basic science research and has about $20 million in in NIH serum funding for her work in stem cells, another fetal minimally invasive therapies. Uh Dr lan Vu, who's been uh my partner for almost 10 years and does a lot of colorectal work in Children and as well as our surgical quality lead uh for the Benioff Children's Hospital san Francisco. Dr Nagel who focuses on a biliary tract diseases in Children and also has a basic science lab. And then along with dr moses, we were very fortunate to recruit Dr Drew Osgood is back to. UCSF Derek was one of our residents as well, Has spent about the last 10 years at Yale and came back to join us. He also does uh work in surgical oncology but really is one of the world's leaders in health disparity in Children and global surgical care. Drug speaks about seven different languages, English, Turkish, uh Mandarin, swahili, spanish and Portuguese. Most of them fluently has for the past 10 years or so. I spent 3-6 months in Uganda where he collaborates with surgeons there on both, learning from them and trying to uh teach some of their residents in some of our tickets as well. And so it's been a great collaboration and back and forth learning. Um So that's our team. We also have a terrific team of advanced practice providers in both the East and the West Bay that you may interact with as well as our clinic administrative staff. And we just have a terrific team. Our team is growing uh and we're always happy to take any referrals