To the Editor,

We read with great interest the article by Moran et al. [1], whose work shows that excision and primary closure with a Karydakis flap is an effective treatment for chronic pilonidal disease. We would like to express our opinion, based on three important questions: First, is the seriousness or involvement of the disease similar in all patients? Second, is only one type of surgical procedure preferred in all patients? Third, is there a correlation between recurrence and extension of the disease? We believe that there must be a difference between the management of a patient with a small asymptomatic pit on the natal cleft and another patient with extensive symptomatic disease where one or more sinus openings lies outside the natal cleft.

A practical and realistic classification system that reflects the extension of the disease should be proposed so that we can compare the results of the surgical procedures according to the type of pilonidal disease being treated. Recently, Tezel proposed such a system that is based on the navicular area concept [2], and Awad et al. have proposed a scoring system to facilitate the decision for management of the disease [3]. Neither of these systems has been accepted worldwide because neither solves the problem. For example, according to the Tezel classification system, similar operations are recommended for different types of pilonidal disease. Further, the scheme proposed by Awad et al. is a scoring system, not a classification system.

Starting anew, we proposed an easy five-point classification system for pilonidal disease based on the natal cleft.

  • Type I: Pit(s) on the natal cleft

  • Type II: Pit(s) on either side of the natal cleft

  • Type III: Pits on both sides of the natal cleft

  • Type IV: Complex pilonidal disease with multiple pits on and beside the natal cleft

  • Type V: Recurrent pilonidal disease (see Table 1)

Table 1 The classification of pilonidal disease
Full size table