Differences between male and female patients with pilonidal disease

•Pilonidal disease has different presentations between male and female patients.•Male and female pilonidal patients differ in pain intensity, drainage, and granuloma formation.•Female patients can have menstruation-related gluteal cleft pain, possibly ameliorated by hormonal contraceptive use.•Menstruation-related gluteal cleft pain could be due to more fibroblasts with androgen and estrogen receptor expression. Pilonidal disease begins in puberty when males and females have different sex hormone expression. We hypothesize that sex differences can lead to clinical differences in pilonidal disease. Patient demographics, Fitzpatrick skin type, hair characteristic, presentation, pain score, recurrence were recorded 2019–2022. All patients underwent regular epilation+/-pit excision. Excised pits were stained for estrogen receptor, progesterone receptor, and androgen receptor. 237 patients (110F, 127 M) were followed 351±327days. Females present younger than males (17.5 ± 3.9 vs.18.4 ± 3.6years). While no sex-related differences noted in recurrence rate (4.5% vs.7.9 %) or skin type, there were significant sex-related differences in hair amount, thickness, density, and color. More males had granuloma than females (34% vs.12 %): 63 % granuloma were located left of midline, 30 % right, 7 % center. More males than females presented with drainage (67% vs.35 %). Significant differences were noted in patient-reported pain: Females’ mean initial pain score was higher than that of males’ (5.6 ± 2.5 vs.4.7 ± 2.2). 35 % females had menstruation-related gluteal cleft pain (MRGCP), not associated with recurrence or pads/tampons use. Females on contraceptives (15.5 %females) had lower pain score than those who were not (3.9 ± 2.7 vs.5.8 ± 2.4) and none of these females reported MRGCP. Patients with drainage had lower pain score than those without (4.5 ± 2.4 vs.5.8 ± 2.2). Excised pits from females with MRGCP had higher proportion of fibroblasts stain positive for estrogen receptor and androgen receptor compared to those without MRGCP (28.4 %±9.0 %vs.14.4 %±6.5 %, 18.0 %±11.7 %vs.6.9 %±9.0 %, respectively). Male and female pilonidal patients differ in pain intensity, drainage, and granuloma formation. More fibroblasts with estrogen receptor and androgen receptor expression is a potential mechanism for MRGCP that is ameliorated by contraceptive use. [Display omitted]