Dermatosurgery – Tricks of the Trade DOI: 10.1111/ddg.12227
Franziska Brehmer 1, Markus Zutt2, Anike Lockmann1, Michael P. Schön1, Kai-Martin Thoms1
Nd:YAG laser epilation to prevent recurrences after pilonidal sinus surgery
(1) Department of Dermatology, University Medical Center Göttingen, Germany (2) Department of Dermatology, Hospital Bremen-Mitte, Germany
Introduction Pilonidal sinus is a common and painful inflammatory disorder of the sacral tissues; it mainly affects men (M:F ratio is 2–4:1) in the 2nd to 3rd decade of life. The disease is found in fairskinned Europeans with an incidence of 26/100 000 people. It rarely occurs in black Africans and Asians [1, 2]. The sinus contains granulation tissue, hairs and cell detritus. The course of disease can be divided in asymptomatic, acute with abscess and chronic exudative. Pilonidal sinuses persist lifelong but can become acute at any moment. In this stage with bacterial superinfection surgical incision and drainage along with antibiotic treatment is recommended. Total excision of the sinus with all its fistula tracts down to the sacral fascia is indicated a non- inflamed phase. The optimal treatment after surgical excision is still controversial. Open secondary wound healing, primary wound closure in the centerline or plastic reconstructive flaps are common treatment options. The relapse rate is high and is estimated at 5 % to 20 % [1, 3]. While some authors report the lowest relapse rate after open wound healing [2, 4], others describe best results after wound closure with flaps [5]. Surgical incision and drainage before definitive total excision reduces the longterm recurrence rate [4]. Hairs not only promote relapse but also hamper the process of secondary wound healing after pilonidal sinus surgery (Figure 1). In recent years epilation with different laser systems has successfully reduced the risk for relapse after pilonidal sinus surgery [3, 5–8].
Technique We performed photoepilation with the Nd:YAG laser at a wavelength of 1064 nm (GentleYAG ®, Candela Laser,
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Figure 1 Extreme perianal hairiness impairing secondary wound healing after pilonidal sinus surgery.
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Dermatosurgery – Tricks of the Trade
Figure 2 Shaving with disposable razor before laser therapy (a). Nd:YAG laser hair removal (b).
Figure 3 Baseline status of another patient after complete secondary wound healing before laser therapy (a), result after three treatments (b), and outcome after five Nd:YAG laser treatments (c).
Neu-Isenburg) with the following parameters: spot size 18 mm, energy density 26–30 J/cm 2 , pulse duration 3 ms, dynamic cooling 40–20–0. Laser treatment included the scar in the rima ani and the adjacent 2 to 3 cm lateral to both sides. The area to be treated was shaved immediately before laser epilation (Figure 2). If necessary a local anesthesia with a lidocaine/tetracaine gel was applied 15 minutes before treatment. Except for slight pain, treatment was generally well tolerated and provided a quick and effective hair reduction (Figure 3). For a satisfying result usually 4 to 6 sessions at 4 to 6 week intervals were necessary.
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© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Discussion Whereas in the past pilonidal sinus was considered a genetic developmental defect, today a multifactorial process with a possible genetic predisposition is favored. Excessive hairs play a central role due to penetration of broken terminal hairs into the subcutaneous adipose tissue with subsequent development of a granuloma [5]. Bacterial superinfection can lead to acute inflammation with abscesses and fistulas. Obesity and poor hygiene are further risk factors [7]. Marked hairiness in the gluteal region increases both the risk for developing a
Dermatosurgery – Tricks of the Trade
pilonidal sinus and the risk for relapse. Frequency of recurrence and severity correlate with the density of hair growth in the gluteal region [7]. Repeated shaving is difficult to perform and generally not recommended [9]. Laser epilation in contrast is a very effective method to reduce hair growth; its efficacy and positive long term effects in preventing relapse after pilonidal sinus surgery has been proven in several studies with up to 60 patients. Different laser systems have been used for epilation, such as the alexandrite laser, diode laser, or as in our case, the Nd:YAG laser [1, 3, 5–8]. Selective photothermolysis leads to destruction of the pigmented hair follicles. Melanin serves as absorber of light energy, which is transformed into heat and consecutively destroys the hair follicles. For this reason only darkly pigmented hairs can be treated successfully while thin and light-colored hairs on dark or tanned skin are frustrating to treat. The surrounding tissue and the epidermis are generally not affected by laser epilation [10]. The decisive advantage of the Nd:YAG laser compared to other laser systems is its deep tissue penetration due to longer wave lengths and longer pulse duration so that even the deep and thick hair follicles of the gluteal region are reached [1]. The absorption maximum for melanin is less for the Nd:YAG laser compared to the alexandrite laser [10]. Possible side effects include slight to moderate pain, transient hypo- or hyper pigmentation and rarely vesiculation. Pain can be prevented with anesthetic gels or creams. In larger studies with at least 15 adult patients, recurrence rates after laser epilation vary from 0 % to 13.3 % [3, 5, 6, 8]. Comparing the various laser systems is difficult because of the small number of patients and varying follow-up periods ranging from 12 months to 5 years. Ghnnam et al. reported about a hair reduction of 100 % after 12 months [8]. Only one study considered the patient satisfaction and stated „satisfied“ or „very satisfied“ in 66 % [5]. Since only approximately 20 % of the hair follicles are reached per treatment (due to the different growth phases) 3 to 8 treatment cycles are necessary [10], according to our experience generally 5 to 6 treatments. Laser epilation leads to a long- lasting, however, not permanent hair removal. For this reason repeated treatments may prove beneficial for the maintenance of an optimal treatment outcome [10].
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Conflict of interest None. Correspondence to Dr. med. Kai-Martin Thoms University Medical Center Göttingen Department of Dermatology Robert-Koch-Straße 40 37075 Göttingen, Germany E-mail: [email protected]
References 1
Lindholt-Jensen CS, Lindholt JS, Beyer M, Lindholt JS. Nd:YAG laser treatment of primary and recurrent pilonidal sinus. Lasers Med Sci 2012; 27: 505–8. 2 Strittmatter B, Breitkopf C, Furtwängler A et al. Leitlinie Pilonidalsinus. Coloproctology 2009; 31: 399–402. 3 Badawy EA, Kanawati MN. Effect of hair removal by Nd:YAG laser on the recurrence of pilonidal sinus. JEADV 2009; 23: 883–6. 4 Doll D, Matevossian E, Hoenemann C, Hoffmann S. Incision and drainage preceding definite surgery achieves lower 20-year long-term recurrence rate in 583 primary pilonidal sinus surgery patients. J Dtsch Dermatol Ges 2013; 11: 60–4. 5 Oram Y, Kahraman F, Karincaoglu Y, Koyuncu E. Evaluation of 60 patients with pilonidal sinus treated with laser epilation after surgery. Dermatol Surg 2010; 36: 88–91. 6 Schulze SM, Patel N, Hertzog D, Fares LG 2nd. Treatment of pilonidal disease with laser epilation. Am Surg 2006; 72: 534–7. 7 Benedetto AV, Lewis AT. Pilonidal sinus disease treated by depilation using an 800 nm diode laser and review of the literature. Dermatol Surg 2005; 31: 587–91. 8 Ghnnam WM, Hafez DM. Laser hair removal as adjunct to surgery for pilonidal sinus: our initial experience. J Cutan Aesthet Surg 2011; 4: 192–5. 9 Petersen S, Wietelmann K, Evers T et al. Long-term effects of postoperative razor epilation in pilonidal sinus disease. Dis Colon Rectum 2009; 52: 131–4. 10 Gansel RW. Photoepilation: State-of-the-Art. Hautarzt 2008; 59: 124–30.
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Franziska Brehmer 1, Markus Zutt2, Anike Lockmann1, Michael P. Schön1, Kai-Martin Thoms1
Nd:YAG laser epilation to prevent recurrences after pilonidal sinus surgery
(1) Department of Dermatology, University Medical Center Göttingen, Germany (2) Department of Dermatology, Hospital Bremen-Mitte, Germany
Introduction Pilonidal sinus is a common and painful inflammatory disorder of the sacral tissues; it mainly affects men (M:F ratio is 2–4:1) in the 2nd to 3rd decade of life. The disease is found in fairskinned Europeans with an incidence of 26/100 000 people. It rarely occurs in black Africans and Asians [1, 2]. The sinus contains granulation tissue, hairs and cell detritus. The course of disease can be divided in asymptomatic, acute with abscess and chronic exudative. Pilonidal sinuses persist lifelong but can become acute at any moment. In this stage with bacterial superinfection surgical incision and drainage along with antibiotic treatment is recommended. Total excision of the sinus with all its fistula tracts down to the sacral fascia is indicated a non- inflamed phase. The optimal treatment after surgical excision is still controversial. Open secondary wound healing, primary wound closure in the centerline or plastic reconstructive flaps are common treatment options. The relapse rate is high and is estimated at 5 % to 20 % [1, 3]. While some authors report the lowest relapse rate after open wound healing [2, 4], others describe best results after wound closure with flaps [5]. Surgical incision and drainage before definitive total excision reduces the longterm recurrence rate [4]. Hairs not only promote relapse but also hamper the process of secondary wound healing after pilonidal sinus surgery (Figure 1). In recent years epilation with different laser systems has successfully reduced the risk for relapse after pilonidal sinus surgery [3, 5–8].
Technique We performed photoepilation with the Nd:YAG laser at a wavelength of 1064 nm (GentleYAG ®, Candela Laser,
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Figure 1 Extreme perianal hairiness impairing secondary wound healing after pilonidal sinus surgery.
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Dermatosurgery – Tricks of the Trade
Figure 2 Shaving with disposable razor before laser therapy (a). Nd:YAG laser hair removal (b).
Figure 3 Baseline status of another patient after complete secondary wound healing before laser therapy (a), result after three treatments (b), and outcome after five Nd:YAG laser treatments (c).
Neu-Isenburg) with the following parameters: spot size 18 mm, energy density 26–30 J/cm 2 , pulse duration 3 ms, dynamic cooling 40–20–0. Laser treatment included the scar in the rima ani and the adjacent 2 to 3 cm lateral to both sides. The area to be treated was shaved immediately before laser epilation (Figure 2). If necessary a local anesthesia with a lidocaine/tetracaine gel was applied 15 minutes before treatment. Except for slight pain, treatment was generally well tolerated and provided a quick and effective hair reduction (Figure 3). For a satisfying result usually 4 to 6 sessions at 4 to 6 week intervals were necessary.
1204
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Discussion Whereas in the past pilonidal sinus was considered a genetic developmental defect, today a multifactorial process with a possible genetic predisposition is favored. Excessive hairs play a central role due to penetration of broken terminal hairs into the subcutaneous adipose tissue with subsequent development of a granuloma [5]. Bacterial superinfection can lead to acute inflammation with abscesses and fistulas. Obesity and poor hygiene are further risk factors [7]. Marked hairiness in the gluteal region increases both the risk for developing a
Dermatosurgery – Tricks of the Trade
pilonidal sinus and the risk for relapse. Frequency of recurrence and severity correlate with the density of hair growth in the gluteal region [7]. Repeated shaving is difficult to perform and generally not recommended [9]. Laser epilation in contrast is a very effective method to reduce hair growth; its efficacy and positive long term effects in preventing relapse after pilonidal sinus surgery has been proven in several studies with up to 60 patients. Different laser systems have been used for epilation, such as the alexandrite laser, diode laser, or as in our case, the Nd:YAG laser [1, 3, 5–8]. Selective photothermolysis leads to destruction of the pigmented hair follicles. Melanin serves as absorber of light energy, which is transformed into heat and consecutively destroys the hair follicles. For this reason only darkly pigmented hairs can be treated successfully while thin and light-colored hairs on dark or tanned skin are frustrating to treat. The surrounding tissue and the epidermis are generally not affected by laser epilation [10]. The decisive advantage of the Nd:YAG laser compared to other laser systems is its deep tissue penetration due to longer wave lengths and longer pulse duration so that even the deep and thick hair follicles of the gluteal region are reached [1]. The absorption maximum for melanin is less for the Nd:YAG laser compared to the alexandrite laser [10]. Possible side effects include slight to moderate pain, transient hypo- or hyper pigmentation and rarely vesiculation. Pain can be prevented with anesthetic gels or creams. In larger studies with at least 15 adult patients, recurrence rates after laser epilation vary from 0 % to 13.3 % [3, 5, 6, 8]. Comparing the various laser systems is difficult because of the small number of patients and varying follow-up periods ranging from 12 months to 5 years. Ghnnam et al. reported about a hair reduction of 100 % after 12 months [8]. Only one study considered the patient satisfaction and stated „satisfied“ or „very satisfied“ in 66 % [5]. Since only approximately 20 % of the hair follicles are reached per treatment (due to the different growth phases) 3 to 8 treatment cycles are necessary [10], according to our experience generally 5 to 6 treatments. Laser epilation leads to a long- lasting, however, not permanent hair removal. For this reason repeated treatments may prove beneficial for the maintenance of an optimal treatment outcome [10].
© The Authors | Journal compilation © Blackwell Verlag GmbH, Berlin | JDDG | 1610-0379/2013/1112
Conflict of interest None. Correspondence to Dr. med. Kai-Martin Thoms University Medical Center Göttingen Department of Dermatology Robert-Koch-Straße 40 37075 Göttingen, Germany E-mail: [email protected]
References 1
Lindholt-Jensen CS, Lindholt JS, Beyer M, Lindholt JS. Nd:YAG laser treatment of primary and recurrent pilonidal sinus. Lasers Med Sci 2012; 27: 505–8. 2 Strittmatter B, Breitkopf C, Furtwängler A et al. Leitlinie Pilonidalsinus. Coloproctology 2009; 31: 399–402. 3 Badawy EA, Kanawati MN. Effect of hair removal by Nd:YAG laser on the recurrence of pilonidal sinus. JEADV 2009; 23: 883–6. 4 Doll D, Matevossian E, Hoenemann C, Hoffmann S. Incision and drainage preceding definite surgery achieves lower 20-year long-term recurrence rate in 583 primary pilonidal sinus surgery patients. J Dtsch Dermatol Ges 2013; 11: 60–4. 5 Oram Y, Kahraman F, Karincaoglu Y, Koyuncu E. Evaluation of 60 patients with pilonidal sinus treated with laser epilation after surgery. Dermatol Surg 2010; 36: 88–91. 6 Schulze SM, Patel N, Hertzog D, Fares LG 2nd. Treatment of pilonidal disease with laser epilation. Am Surg 2006; 72: 534–7. 7 Benedetto AV, Lewis AT. Pilonidal sinus disease treated by depilation using an 800 nm diode laser and review of the literature. Dermatol Surg 2005; 31: 587–91. 8 Ghnnam WM, Hafez DM. Laser hair removal as adjunct to surgery for pilonidal sinus: our initial experience. J Cutan Aesthet Surg 2011; 4: 192–5. 9 Petersen S, Wietelmann K, Evers T et al. Long-term effects of postoperative razor epilation in pilonidal sinus disease. Dis Colon Rectum 2009; 52: 131–4. 10 Gansel RW. Photoepilation: State-of-the-Art. Hautarzt 2008; 59: 124–30.
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