Name of the Condition

• Pilonidal cyst with abscess (ICD-10 code: L05.01)

Summary

• A pilonidal cyst is a painful, swollen area near the tailbone that often contains hair and skin debris. When infected, it forms an abscess—a pocket of pus that causes significant discomfort and swelling.

Causes

• Pilonidal cysts can arise from a combination of hair, friction, and pressure. They commonly develop when hair punctures the skin and is pushed beneath it. Infection can occur, leading to abscess formation.

Risk Factors

• Common risk factors include being male, between puberty and early 30s, having a sedentary lifestyle, excessive hair in the affected area, and poor hygiene.

Symptoms

• Symptoms include swelling, redness, and pain at the base of the spine, drainage of pus or blood, fever, and a tender lump under the skin.

Diagnosis

• Diagnosis is typically based on a physical examination of the affected area. A healthcare provider looks for signs of infection, such as redness, swelling, and discharge.

Treatment Options

• Incision and Drainage: The primary treatment for an abscess is surgical drainage.
• Antibiotics: Prescribed if there are signs of a spreading infection.

• Surgical Excision: Complete removal of the cyst may be necessary for recurrent cases.

  Prognosis and Follow-Up

• With proper treatment, the outlook is generally good. However, cysts can recur, necessitating follow-up visits to monitor healing and prevent future occurrences.

Complications

• Potential complications include chronic infection, persistent drainage, and recurrence of the cyst.

Lifestyle & Prevention

• Maintaining good hygiene, reducing time spent sitting, and losing weight may help reduce risk. Regular hair removal in the area may also be beneficial for prevention.

When to Seek Professional Help

• Seek medical attention if you experience severe pain, persistent redness, swelling, or drainage near the tailbone area, especially if accompanied by fever.

Additional Resources

• American Academy of Dermatology (AAD): www.aad.org
• National Institutes of Health (NIH): www.nih.gov

Tips for Medical Coders

• Ensure the distinction between simple pilonidal cysts and those with abscesses.
• Be attentive to documentation detail, as management varies significantly.