What is the treatment guideline for a stye (hordeolum)?

Treatment Guidelines for Stye (Hordeolum)

The primary treatment for a stye (hordeolum) consists of warm compresses and eyelid cleansing, with antibiotics reserved for cases that don't respond to conservative management or show signs of spreading infection. 1

First-Line Treatment

Warm Compresses

• Apply warm compresses to the affected eyelid for several minutes (3-5 minutes) multiple times daily
• This helps soften adherent crusts and scales, and warms the meibomian secretions
• Can be achieved using:
  • Hot tap water on a clean washcloth
  • Over-the-counter heat pack
  • Homemade bean/rice bag heated in microwave
• Important safety note: Ensure compresses are not hot enough to burn the skin

Eyelid Cleansing

• Perform gentle massage of the eyelids after applying warm compresses
• For posterior blepharitis/internal hordeolum: Use vertical massage to express meibomian secretions
• For anterior blepharitis/external hordeolum: Gently rub the base of eyelashes to remove crusting
• Cleaning options include:
  • Diluted baby shampoo
  • Commercial eyelid cleaners
  • Hypochlorous acid 0.01% cleaners (particularly effective for anterior blepharitis)
  • Use a cotton ball, pad, cotton swab, or clean fingertip

Second-Line Treatment

Antibiotics

If the stye doesn't improve with warm compresses and cleansing after several days, or if there are signs of spreading infection:

Topical Antibiotics

• Apply antibiotic ointment to the affected eyelid lining
• Options include:
  • Erythromycin ointment
  • Levofloxacin (hydrochloric levofloxacin) 2

Systemic Antibiotics

• Reserved for severe cases with spreading infection or multiple recurrent styes
• Should target common pathogens (Staphylococcus aureus, coagulase-negative Staphylococcus, Streptococcus species) 1

Treatment Algorithm

1. Initial presentation of stye:

   • Begin warm compresses 3-4 times daily for 5-10 minutes
   • Implement eyelid cleansing with gentle massage after compresses
   • Avoid eye makeup and contact lenses until resolved

2. After 48-72 hours with no improvement:

   • Continue warm compresses and cleansing
   • Consider adding topical antibiotic ointment

3. If worsening or spreading infection:

   • Evaluate for signs of preseptal cellulitis (spreading redness, swelling beyond eyelid)
   • Consider systemic antibiotics if infection is spreading

4. For recurrent styes:

   • Evaluate for underlying blepharitis or meibomian gland dysfunction
   • Implement daily eyelid hygiene as preventive measure
   • Consider evaluation for conditions that predispose to blepharitis (rosacea, seborrheic dermatitis)

Special Considerations

Surgical Intervention

• Most styes resolve with conservative management
• Incision and drainage may be considered for persistent cases that don't respond to medical therapy
• A biopsy should be considered for recurrent, unilateral styes in the same location to rule out malignancy 1

Pre-Operative Management

• For patients planning intraocular surgery, addressing moderate to severe blepharitis with topical antibiotics and eyelid hygiene is recommended to reduce risk of post-operative infection 1

Cautions

• Avoid squeezing or attempting to "pop" a stye, which can spread infection
• Be aware that long-term antibiotic treatment may result in development of resistant organisms 1
• If a stye is persistent, recurrent in the same location, or associated with eyelash loss, consider referral to rule out sebaceous carcinoma 1

Patient Education

• Explain that styes are common and typically resolve within 1-2 weeks with proper care
• Emphasize that treatment is aimed at symptom management and preventing spread of infection
• Advise that recurrences are common and may require ongoing eyelid hygiene

Remember that while most styes resolve with conservative management, persistent or recurrent cases warrant further evaluation to rule out more serious conditions.