What is the recommended treatment for a small stye (hordeolum)?

Treatment of Small Stye (Hordeolum)

Warm compresses and gentle eyelid cleansing are the recommended first-line treatments for a small stye (hordeolum). 1

Understanding Styes

A stye (hordeolum) is a painful, localized inflammation of the eyelid margin typically caused by bacterial infection affecting the oil glands of the eyelid. Styes can be:

• Internal (affecting meibomian glands)
• External (affecting glands of Zeis or Moll)

Treatment Algorithm

First-Line Treatment:

1. Warm compresses

   • Apply to the affected eyelid for several minutes (3-5 minutes)
   • Use 3-4 times daily
   • Helps to soften discharge, warm meibomian secretions, and promote drainage
   • Can be achieved using:
     • Hot tap water on a clean washcloth
     • Over-the-counter heat pack
     • Homemade bean/rice bag heated in microwave
   • Important: Ensure temperature is comfortable and not hot enough to burn skin

2. Eyelid cleansing

   • Gently massage the eyelid after applying warm compresses
   • Clean the eyelid margin using:
     • Diluted baby shampoo
     • Commercial eyelid cleaner
     • Hypochlorous acid 0.01% cleaners (have antimicrobial effects)
   • Use a clean pad, cotton ball, cotton swab, or clean fingertip
   • Perform once or twice daily

Second-Line Treatment (for non-resolving or worsening styes):

• Topical antibiotics
  • Antibiotic ointment (such as bacitracin or erythromycin) applied to eyelid margin
  • Apply 1-2 times daily

When to Consider Additional Interventions:

• If the stye fails to improve after 48-72 hours of conservative treatment
• If there are signs of spreading infection (increasing redness, swelling beyond the initial area)
• If vision is affected
• If multiple recurrences occur

Important Considerations

• Most styes will drain spontaneously and resolve without treatment within 7-10 days 2, 3
• Avoid squeezing or attempting to "pop" the stye as this may spread infection
• Avoid eye makeup until the stye resolves
• Avoid contact lens wear during active infection

Cautions and Pitfalls

1. Manual dexterity concerns: Eyelid cleansing using cotton swabs or digital massage can potentially be dangerous if the patient lacks manual dexterity or proper technique 1

2. Patients with glaucoma: Those with advanced glaucoma should avoid aggressive lid pressure during massage as it may increase intraocular pressure 1

3. Neurotrophic corneas: Patients with decreased corneal sensation require careful counseling to avoid corneal epithelial injury during lid hygiene 1

4. Misdiagnosis: Ensure the lesion is actually a stye and not a more serious condition like sebaceous carcinoma, which can masquerade as recurrent chalazia/styes 1

5. Antibiotic resistance: Long-term antibiotic treatment may result in development of resistant organisms, so limit use to cases that don't respond to warm compresses and lid hygiene 1

Despite the common recommendation of antibiotics for styes, there is limited high-quality evidence supporting their routine use for uncomplicated cases 2, 3. The most recent guidelines emphasize warm compresses and eyelid hygiene as the mainstay of treatment, with antibiotics reserved for cases that don't respond to conservative measures or show signs of spreading infection.