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Article

Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults?

by
Christina Oetzmann von Sochaczewski
1,*,
Theo Hackmann
2,
Henrike Heitmann
2,
Myriam Braun-Münker
3,
Matthias Maak
4,5 and
Dietrich Doll
2,6
1
Chirurgische Klinik, Universitätsklinikum Bonn, 53127 Bonn, Germany
2
Vechtaer Institut für Forschungsförderung, 49377 Vechta, Germany
3
Fachbereich Lebensmitteltechnologie, Hochschule Fulda, 36037 Fulda, Germany
4
Chirurgische Klinik, Kreiskrankenhaus St. Anna, 91315 Höchstadt an der Aisch, Germany
5
Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
6
Abteilung für Proktochirurgie und Pilonidalsinus, St. Marienhospital Vechta, 49377 Vechta, Germany
*
Author to whom correspondence should be addressed.
Surgeries 2025, 6(3), 60; https://doi.org/10.3390/surgeries6030060
Submission received: 5 June 2025 / Revised: 10 July 2025 / Accepted: 17 July 2025 / Published: 21 July 2025

Abstract

Background/Objectives: Treatment strategies in pilonidal sinus disease differ substantially between adults and children. While a single surgery with off-midline flap closure is recommended for adults, minimally invasive procedures are preferred in children due to their much higher recurrence rates. Recently, this strategy has been extended to young adults, but long-term recurrence rates in this age group are unknown. Methods: An established database of studies on pilonidal sinus disease was used for the present study. All entries providing information on age and recurrence over time were included. We compared recurrence rates between children (<18 years), young adults (18 to 21 years), and older adults (>21 years) using Kaplan–Meier curves. Between-groups testing employed the two-tailed log rank test. Results: We included 856 entries with 88,348 patients, of which 5635 were children and 3999 young adults. The 5-year recurrence rate in children was 45.1% (95% confidence interval: 40.2–49.7%). For older adults it was 11.5% (95% confidence interval: 11.1–11.8%) and 8.7% (95% confidence interval: 7.4–10%) in young adults. The recurrence rate in young adults was lower than in children (log rank p < 0.001) and comparable, albeit slightly lower, to older adults (log rank p < 0.001). Conclusions: Our results indicate that recurrence rates between young and older adults are similar. Consequently, treatment strategies for young adults could follow the recommendations for adults instead of those for children. Due to the limited quality of available evidence, this requires validation in primary studies with sufficiently long follow-up.

1. Introduction

The incidence and prevalence of pilonidal sinus disease are increasing worldwide and in all age groups [1,2,3,4]. Traditionally, pilonidal sinus disease has been addressed by wide excision followed either by closure by secondary intention or primary (off)-midline closure [5,6]. This approach has also been the favourite method of treatment in children [7]. The mainstay of surgical therapy for a symptomatic pilonidal sinus in adults are excision and flap-based closures due to their small recurrence rate compared to other surgical options [8,9]. Consequently, national guidelines from Germany [10], Italy [11], and the United States of America [12] recommend them as first choice in adults, while the Dutch guideline only recommends them for complex disease [13]. The two commonly used flap procedures are the Karydakis flap, in its traditional [14,15] or in its modified [16] form, and the Limberg flap, also used in its traditional [17,18] or a modified [19] form. The paradigm change, from excision and open wound treatment towards flap procedures has been embraced with differing enthusiasm: In some countries, the traditional approach is still preferred [20,21,22,23], while others changed their practice towards flaps [24]. However, many were somewhere in between, which has been associated with the extent and depth of surgical training [25,26,27,28]. An issue that had been raised earlier in the debate around who should treat patients with pilonidal sinus disease, arguing that colorectal surgeons often lacked the expertise for flap procedures due to their different training [29].
On the contrary, children and adolescents experience much higher rates of recurrence, irrespective of the chosen surgical therapy, may it be trephination, flaps, endoscopic or laser [30,31,32,33,34]. An issue specific to children is recurrences that occur earlier than in adults [35,36]. This poses a particular problem, as the incidence of pilonidal sinus disease is increasing, especially in adolescents and young adults [1,4]. This has been attributed to puberty and its associated hormonal changes [37], although a relationship between hormonal levels and pilonidal sinus disease could not be demonstrated [38]. This has been addressed by developing minimally invasive protocols for children and adolescents in order to minimise the disease’s impact on the patient’s formative phase of life by focusing on office-based procedures [39,40,41] or endoscopic approaches [42,43,44]. These approaches have subsequently been adapted at many centres [33,45,46,47,48,49,50,51,52] but also include young adults [45,46,47]. For them, evidence supporting the extension of these minimally invasive protocols to this age group is missing. We, therefore, aimed to investigate if the pattern of recurrence in young adults would follow those of children and adolescents or the one observed in older adults.

2. Materials and Methods

The present study used an established database [8,36,53,54,55,56]. We screened all database records for the inclusion criteria—patient age, definitive treatment and surgical approach, and the duration of follow-up—and the exclusion criteria—pilonidal sinus disease localised anywhere else than the pre-sacral region, concurrent neoplasia, and potential duplicate publication of the same group—and also excluded reviews and meta-analyses. Studies that based their assessment of pilonidal sinus disease recurrence solely on patients that returned due to recurrence without follow-up for non-returning patients—the return on recurrence approach—were excluded. Due to the small number of available data for children, adolescents, and young adults, the different surgical approaches were pooled. We assumed, based on systematic reviews of pilonidal sinus disease treatment in children and adolescents, that none of the surgical approaches was superior to the others [39,57]. Their findings support pooling the data irrespective of the surgical approach.
Young adults were defined as between 18, marking the legal age nowadays in many countries, and 21 years of age, which has traditionally been the age to become an adult in many countries and still is in several others. The age of 21 has been determined on currently accepted limits of adolescence based on the end of physiologic maturation into an adult [58,59].
Using an established methodology [8,36,53,54,55,56], in order to allow comparison between age groups, single patients were simulated to reflect recurrences. For example, if a study reported a recurrence rate of 10% in a sample of 100 patients, we simulated 10 single patients that experienced a recurrence, but 90 that did not. In order to make the different measures of reported follow-up time comparable, we used the reported centre of the range of follow-up times. This seemed reasonable as pilonidal sinus disease clusters in young adults [1,37,60]. The number of patients at risk was calculated as described before [8,61]: If detailed numbers at risk were provided, these were used. If they were not, we used linear interpolation between the two nearest reported follow-up times of the respective database entry. For statistical analysis, we used R (version 4.3.2) [62]. Recurrence-free outcome over time was assessed by survival analysis with Kaplan–Meier estimators with pointwise 95% confidence intervals using the survival-package (version 3.5-7) [63]. The Kaplan–Meier plots were generated with the help of the survminer-package (version 0.4.9) [64]. Colourblind-friendly graphs were drawn using the viridis-package (version 0.6.4) [65]. The recurrence-free outcome between the age groups was determined using the two-sided log rank test.

3. Results

We identified 7790 records, of which 7555 were screened, and 856 entries were included into the analysis. The included entries represented 88,348 individual patients, of whom 5635 were less than 18 years old, 3999 between 18 and 21 years of age, and another 78,714 patients were older than 21 years.
We found the recurrence-free outcome of children to be much lower than in adults, whose recurrence-free outcome seemed similar between young adults and older adults (Figure 1). The 5-year recurrence rate for children was 45.1% (95% confidence interval: 40.2–49.7%). For young adults, aged 18 to 21 years, it was 8.7% (95% confidence interval: 7.4–10%), and for older adults the 5-year recurrence rate was 11.5% (95% confidence interval: 11.1–11.8%) (Figure 1).
In the direct comparison between children and young adults, the latter had a much higher recurrence-free outcome (log rank test p < 0.001) (Figure 2).
This was also true for the comparison between young adults and older adults (log rank test p < 0.001) (Figure 3).
Likewise, the number at risk was also substantially different: The number of young adults was almost 7-fold higher than children after 5 years. Likewise, the number of older adults was almost 14-fold higher than those of young adults (Figure 1).

4. Discussion

Children had not been explicitly considered in national guidelines on pilonidal sinus disease [10,11,12]. Their higher recurrence rates irrespective of the chosen surgical approach [35] suggested that a different approach to their pilonidal sinus disease might be more suitable. The favourable results reported from meta-studies [8,9] could not be achieved in children, but the underlying reasons remain unclear. A systematic review had demonstrated in 2019 that the traditional approach of wide excision and secondary closure had unacceptably high recurrence rates of 26% [57]. Flap procedures and minimally invasive surgeries had similar recurrence rates in this systematic review [57], which resulted in favouring the minimally invasive options for the treatment of children and adolescents, because the impact on their daily lives is smaller [40,41]. This may be exemplified by preceding reviews that were much more cautious regarding minimally invasive approaches in children and adolescents [66,67]. The subsequently developed treatment algorithms aimed to improve surgical therapy of pilonidal sinus disease in children and adolescents to alleviate their high burden of recurrences [39,40,41]. Recent reports that followed these recommendations and used minimally invasive approaches extended this treatment to young adults [44,45,46,47,68,69,70,71,72], although meta-studies suggested inferior long-term outcomes in adults [8]. There are several methods used for children that were extended to young adults: Among these are endoscopic therapy [44,70,71,73], trephination with primary closure of the pit excision [45,46,48], trephination with the pit excision left open for secondary closure [30,47,68], and trephination or pit-picking [72]. The basis of these minimally invasive protocols is the increased recurrence rate in children and adolescents [39,41,57]. We, therefore, investigated whether an increased recurrence rate could also be found in young adults.
Traditionally, pilonidal sinus disease in children and adolescents had been addressed by excisional procedures [74]. This approach was continued into the 20th century [7]. Interestingly, paediatric pilonidal sinus disease has rarely been considered in the paediatric surgical literature before the millennium [7], despite several descriptions of cases in the literature in the preceding century [74,75,76,77,78,79]. Since then, several other treatment approaches have been tested due to the increased recurrence rates that children and adolescents experienced with the traditional method [35]. The first introduced modifications were negative pressure wound therapy either for primary closure [80] or secondary closure after traditional excision [81]. The Karydakis flap for off-midline closure was the first flap to be comparatively evaluated in the paediatric population [82]. Then, marsupialisation [83], laser epilation [84], the Limberg flap [85], and the cleft lift procedure [86] were introduced and paved the way for the many more treatment variations to follow. However, none of the different approaches that were evaluated has substantially changed that. The old surgical adage that none of the multiple available procedures is ideal if there are many of them [87], is still true for paediatric pilonidal sinus disease.
Using an established methodology to compile results, we found that young adults had recurrence rates that were numerically even smaller than in adults. We assume the statistically significant difference in the log rank test to be caused by the proportionately much larger patient number in the adult group with its associated smaller 95% confidence interval. Nevertheless, in our study, the 5-year recurrence-free outcome in young adults was not higher than in older adults. This result would not have been surprising as an influence of puberty and associated maturational changes had been suggested epidemiologically [1,37], but relevant differences in the hormonal status of pilonidal sinus patients could not be demonstrated [38]. Consequently, it has been assumed that it is unlikely that the 18th birthday would eliminate the factors that drive the paediatric pattern of increased recurrence rates [34]. Our results, however, indicate that this might indeed be the case. We were unable to demonstrate a similarly increased recurrence rate in young adults. This seems to be a feature of paediatric pilonidal sinus disease as it is consistently only present in children and adolescents. This finding enables us to speculate that there might be a different explanation, not linked to hormonal changes. It might rather be a maturational change during puberty linked to the onset of disease, but without influencing recurrence rates after coming-of-age. This could be reflected in the increase in axial hair strength during maturation to a maximum during the second decade of life and its following decrease afterwards [88]. Support from this might be drawn from the incidence rates that also follow a similar pattern [1,4] and the identification of hair and androgen-related traits in a genome-wide association study [89]. However, this is just speculation based on associations, but not a definitive proof of causation.
The importance of hair strength would also be supported by the pathogenesis of pilonidal sinus disease. While it is nowadays accepted that pilonidal sinus disease is an acquired disease [5,6,90,91,92], it had long been thought to be of congenital origin [76,77,93,94]. This assumption had been shattered by descriptions of a pilonidal sinus disease at barber’s hands [95,96]. There are several theories how pilonidal sinus disease develops, all of which have in common that hairs have a crucial role [15,97,98,99]. In brief, sharp hair fragments are torn into the skin on the cranial end of the rima ani resulting in pit formation. Due to its sharpness, the hair then migrates into the subcutaneous fat tissue and elicits a foreign body reaction. It does not resolve on its own, explaining the asymptomatic form of pilonidal sinus disease, and might become infected, resulting in the acute form. On the contrary, Bascom’s theory of hyperkeratinisation [100], in which loose hair enters the already existing pits, is able to explain the occurrence of pilonidal sinus disease and the occurrence of multiple midline pits at the beginning of the disease [99]. The successful application of laser hair removal in a randomised controlled trial [101] also points to this theory: Hair removal around the natal cleft results in a reduced contact time of hair and skin and thus less material to be collected in the sinus cavities. As these issues cannot be explained by the Karydakis’ theory of skin-penetrating sharp hairs, additional work is necessary to fully elucidate the pathogenesis of pilonidal sinus disease.
Another issue is the definition of young adults, limited in this study to the period from 18 to 21 years. This definition follows an established time frame based on physiologic parameters such as the end of skeletal maturation [58,59]. However, this definition has recently been challenged and it has been suggested to expand this time frame up to 24 years of age [102]. This expansion into the next decade has been contested, which is why we stuck to the traditional time frame. Additional support for this could also be drawn from the definition of adulthood, which varies between countries. Nowadays, many countries define adulthood legally as the 18th birthday, but in the past, it has almost universally been the 21st birthday. This definition is still prevalent worldwide for many countries, indicating that the 18th birthday marking adulthood in Western societies might not be universally transferrable. This also suggests that investigating when the treatment should be changed to an adult approach in pilonidal sinus disease was of relevance. Guidelines [10,11,12] apply to adults, but given the association to an increased odds of negative outcomes after failed preceding surgeries [103,104,105], it has been suggested that this aspect required further scrutiny.
The long awaited results of the laser hair removal trial [106] demonstrated that young adults also benefit from this additional intervention [101], but not all populations to the same extent [107]. The raison d’être of the minimally invasive approach, the high recurrence rate observed in children with subsequently necessary multiple procedures, does not persist into adulthood. Multiple minimally invasive procedures in children aim to preserve the anatomy [57], to avoid substantial changes due to multiple failed procedures for the definitive therapy in adulthood [108]. This aspect is of relevance, because multiple failed procedures have been associated with a worsened outcome after each subsequent surgical therapy [103,104,105].
Although our results seem rather compelling, there are relevant limitations, in particular with respect to generalisability of the results. The first issue are the vastly different patient numbers in the different age groups. Although they seem to be large enough at the start of the follow-up period with several thousands in each group, the number substantially decreases after the first years and is vastly different after 5 years. The number of young adults is almost 7-fold higher than those of children, and the number of older adults is almost 14-fold higher than that of young adults. This results in the number of older adults being almost 96-fold higher than those of children.
Another problem for our report is the quality of the included studies: It has been bemoaned before that the quality of evidence for pilonidal sinus disease in children is limited at best [91,109]. The currently available evidence is generally presumed to be of low quality, allowing only conclusions with relevant uncertainty [9,39,57]. This limited quality of evidence inevitably extends into meta-studies and may, thus, infect their results [110]. Even though we tried to maintain a level of quality robust enough to substantiate our claims, the quality of the included studies remains a limitation.
Linked to this is also the necessity to pool the included entries irrespective of the used surgical approach as another limitation. Due to the many available techniques to operate a pilonidal sinus disease [87,109], nearly all of them are present in the pooled analysis. This might alter the recurrence rates over time due to a possible overrepresentation of an approach with more favourable or more negative outcome. Although stratification by surgical technique would have been preferable, the limited number of available patients per stratum was often too low for meaningful results. This might be exemplified by the low numbers of children with a follow-up beyond 40 months in the pooled analysis.
The exclusion of studies with return on recurrence might also limit the generalisability of our results. The reason for defining this exclusion criterion originates from the substantial differences in recurrence rates compared to other studies not using that criterion. Compared to randomised-controlled trials, the recurrence rates in trials using return on recurrence was substantially lower [54], indicating that several recurrences were not captured with return on recurrence. This might also be exemplified using the observational PITSTOP study from the United Kingdom. It reported a loss to follow-up of 28.5% of patients in a study duration of just six months postoperatively [111]. In absolute numbers, 190 of 667 patients were lost to follow-up after these six months [111]. It had been demonstrated in the past for inguinal hernia that recurrences were often treated a different hospital than the primary disease operation [112]. It is likely that a recurrence in pilonidal sinus disease might also be perceived as an adverse event, which prompts patients to seek treatment at a different hospital. Although it has not been investigated if these findings from inguinal hernia could be transferred to pilonidal sinus disease, it does seem like a likely explanation for the lower recurrence rates noted in return on recurrence studies. We, therefore, feel that applying this exclusion criterion is justified in order to avoid selection bias by including studies skewed to lower recurrence rates.
Additional support for that exclusion criterion might be drawn from surveys reporting that almost a third of respondents operated on a share of up to 30% of recurrences in their individual practice [26]. This indicates that current studies reporting particularly low recurrence rates [113] might not be representative. A notion that is corroborated by studies from the same university, which had been unable to confirm similarly low recurrence rates using the same method [114]. This supported by current cohorts that report a large number of already previously operated patients among their cohort irrespective of the surgical approach [48,115]. Similarly high recurrence rates were also observed in the only available paediatric randomised-controlled trial [101].
Lastly, another limitation of our work is the assumption we had to make about the data such as using the reported centre of the follow-up times. While this might be sufficiently precise for the majority of cases, it is likely that it might not be applicable for some of the included entries. This could be the case for a distorted distribution of follow-up times due to some pilot patients with lengthy follow-ups, whereas the majority of included patients had much shorter follow-up times. However, these might be extremes of the spectrum and consequently rare among the included entries. This is also likely to be the case for the studies that had slightly overlapping age cohorts. Although age cohorts including octogenarians and children ending up in a mean age in between these extremes are theoretically possible, the chances for such a cohort to exist are sufficiently low. We might, therefore, assume that these potential distortions are rare and, thus, unlikely to have a relevant impact on the results. Nonetheless, we cannot exclude such an influence on a lower level given the unavailability of original data in many cases, which would then have allowed an individual patient meta-analysis.
Taken together, our results indicate that the treatment strategy developed for children should only warily extended to young adults. If it is extended to young adults, this requires long-term follow-up to judge the success of this approach. Their pilonidal sinus disease might be addressed with similar success in a single surgery as in older adults, but confirmation by primary studies with more than short-term follow-up should be sought. Only with this additional information will it be possible to determine which would be the most beneficial approach in this age group. It would be beyond the aim of our study and also unreasonable to detail any treatment recommendations.

Author Contributions

C.O.v.S.: Conceptualisation, investigation, writing—original draft, writing—review and editing; T.H.: Data curation, formal analysis, investigation, visualisation, writing—review and editing; H.H.: Data curation, formal analysis, investigation, methodology, software, writing—review and editing; M.B.-M.: Methodology, software, supervision, validation, writing—review and editing; M.M.: Methodology, supervision, validation, writing—review and editing; D.D.: Conceptualisation, data curation, formal analysis, investigation, methodology, project administration, supervision, writing—original draft. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The datasets analysed during the current study are available from the senior author on request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Kaplan–Meier curves for the recurrence-free outcome of children, young adults, and older adults following surgery for pilonidal sinus disease. Children were all patients whose age was <18 years. Young adults were defined as being 18–21 years old, and older adults were more than 21 years old. Dashed lines represent the 95% confidence interval.
Figure 1. Kaplan–Meier curves for the recurrence-free outcome of children, young adults, and older adults following surgery for pilonidal sinus disease. Children were all patients whose age was <18 years. Young adults were defined as being 18–21 years old, and older adults were more than 21 years old. Dashed lines represent the 95% confidence interval.
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Figure 2. Comparison of the recurrence-free outcome of children and young adults following surgery for pilonidal sinus disease. Children were patients <18 years old, whereas young adults were 18 to 21 years old. Young adults had a much higher recurrence-free outcome than children (two-tailed log rank test p < 0.001). Dashed lines represent the 95% confidence interval.
Figure 2. Comparison of the recurrence-free outcome of children and young adults following surgery for pilonidal sinus disease. Children were patients <18 years old, whereas young adults were 18 to 21 years old. Young adults had a much higher recurrence-free outcome than children (two-tailed log rank test p < 0.001). Dashed lines represent the 95% confidence interval.
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Figure 3. Comparison of the recurrence-free outcome of young and older adults following surgery for pilonidal sinus disease. Recurrence-free outcome was comparable between young adults (age 18 to 21 years) and older adults (above 21 years), albeit slightly lower in young adults (two-tailed log rank test p < 0.001). Dashed lines represent the 95% confidence interval.
Figure 3. Comparison of the recurrence-free outcome of young and older adults following surgery for pilonidal sinus disease. Recurrence-free outcome was comparable between young adults (age 18 to 21 years) and older adults (above 21 years), albeit slightly lower in young adults (two-tailed log rank test p < 0.001). Dashed lines represent the 95% confidence interval.
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Oetzmann von Sochaczewski, C.; Hackmann, T.; Heitmann, H.; Braun-Münker, M.; Maak, M.; Doll, D. Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults? Surgeries 2025, 6, 60. https://doi.org/10.3390/surgeries6030060

AMA Style

Oetzmann von Sochaczewski C, Hackmann T, Heitmann H, Braun-Münker M, Maak M, Doll D. Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults? Surgeries. 2025; 6(3):60. https://doi.org/10.3390/surgeries6030060

Chicago/Turabian Style

Oetzmann von Sochaczewski, Christina, Theo Hackmann, Henrike Heitmann, Myriam Braun-Münker, Matthias Maak, and Dietrich Doll. 2025. "Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults?" Surgeries 6, no. 3: 60. https://doi.org/10.3390/surgeries6030060

APA Style

Oetzmann von Sochaczewski, C., Hackmann, T., Heitmann, H., Braun-Münker, M., Maak, M., & Doll, D. (2025). Pilonidal Sinus Recurrence Rates in Young Adults—Similar to Children or Adults? Surgeries, 6(3), 60. https://doi.org/10.3390/surgeries6030060

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