There has been much controversy regarding the cause of pilonidal disease. Hair being found in the pilonidal cysts confirmed the probability that hair is forced in by a variety of causes. The author discusses the clinical presentations of pilonidal sinus, differential diagnosis, recurrence rate and techniques of recurrence rate modifications, recurrence rate and surgical therapy, recurrence rate estimation and follow up, and various techniques. New techniques are trying to reduce the surgical trauma while keeping the recurrence rate low. These new techniques still have to prove their efficiency in terms of long-term recurrence rate.