When bacteria in pilonidal cysts or abscesses are cultured we find that the majority of them are “anaerobic bacteria”, which are the kind of bacteria that thrive in an environment without oxygen. This is why the antibiotics that we give before and after cleft-lift surgery are specifically chosen to target that kind of bacteria. Metronidazole is one of the best antibiotics to eradicate anaerobic bacteria, but it is not a treatment for a pilonidal abscess, pilonidal “pits”, or a pilonidal sinus. Those problems require different kinds of treatment, and usually some kind of surgical intervention. Just treating the bacteria will not solve the problem; removal of the cyst or sinus, and flattening the gluteal cleft are the best strategies for permanently curing pilonidal disease.
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There are times after surgery that we want the lower portion of the wound, which is near the anus, to have more prolonged anaerobic bacteria coverage, and have found that metronidazole ointment works well for this. The types of topical metronidazole available in United States pharmacies come in very weak strengths (0.75% or 1%). In Europe they have a 10% metronidazole ointment, marketed under the name Ortem™, but this branded product is not approved for sale here in the United States. This 10% ointment has been shown to be very effective in treating pilonidal wounds in some situations.
Our solution to the issue of unavailability of pre-made 10% metronidazole in the United States is to have a compounding pharmacy make 10% metronidazole for our patients on an individual basis, using FDA approved components. If I have prescribed this for you, we will call the order into a compounding pharmacy, and they will make it up for you, bill you, and send it directly to you. Unfortunately, this may not be covered by your insurance, and may cost around $85.
The usual recommendation is to use this for six to eight weeks – but if your wound looks good, and we have complete healing before then, it may not be necessary to use it for that long.
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