What is the treatment for multiple styes (hordeolum)?

Treatment for Multiple Styes (Hordeolum)

The most effective treatment for multiple styes involves warm compresses, eyelid hygiene, and topical antibiotics, with oral antibiotics reserved for more severe or persistent cases. 1

First-Line Treatment

Warm Compresses

• Apply warm compresses to the eyelids for 10-15 minutes, 3-4 times daily 1
• Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave 2
• Ensure temperature is warm but not hot enough to burn skin 2
• This helps soften crusts and warm meibomian secretions 2

Eyelid Cleansing

• Gently massage eyelids after applying warm compresses 2
• Clean eyelid margins using:
  • Diluted baby shampoo on a cotton pad, ball, swab, or clean fingertip 1
  • Commercially available eyelid cleaners (especially those with 0.01% hypochlorous acid) 2
• For posterior blepharitis/MGD: perform vertical massage to express meibomian glands 2
• For anterior blepharitis: rub eyelid margins side-to-side to remove crusting from eyelashes 2

Second-Line Treatment

Topical Antibiotics

• Apply antibiotic ointment such as bacitracin or erythromycin to eyelid margins 2
• Use once or more daily or at bedtime for a few weeks 2
• Consider rotating different antibiotics to prevent resistance 2

Artificial Tears

• Use preservative-free artificial tears if applying more than 4 times daily 2
• Consider lipid-containing supplements if meibomian gland dysfunction is present 2

Third-Line Treatment

Oral Antibiotics

• For moderate to severe cases not responding to topical treatment 2
• Options include:
  • Doxycycline, minocycline, or tetracycline (tapered after clinical improvement) 2
  • Oral erythromycin or azithromycin (especially for women of childbearing age and children) 2
  • These medications also have anti-inflammatory properties 2

Topical Anti-inflammatory Agents

• Short-term use of topical corticosteroids for moderate to severe inflammation 2
• Consider combination antibiotic/steroid treatments for moderate to severe cases 1
• For long-term management, transition to cyclosporine after initial steroid treatment 2

Special Considerations

Precautions

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage 2
• Patients with neurotrophic corneas need careful counseling to avoid corneal epithelial injury 2
• Patients lacking manual dexterity should use caution with cotton swabs or digital massage 2

Duration of Treatment

• Advise patients that treatment is typically long-term 1
• Symptoms often recur when treatment is discontinued 2
• Regular eyelid cleansing (daily or several times weekly) helps manage chronic symptoms 2

When to Refer

• For persistent styes (lasting >2 months) or those developing into chalazia 1
• For aggressive infections with signs of systemic toxicity 1
• Consider surgical intervention (incision and curettage) for persistent or large chalazia 1

Prevention

• Practice good eyelid hygiene regularly 1
• Remove eye makeup completely 1
• Treat underlying conditions (like rosacea) that may predispose to styes 1
• If contact lens wearer, discontinue use until stye resolves and consider replacing lenses and case afterward 1

While there is limited high-quality evidence specifically for multiple styes, the treatment approach follows established guidelines for individual styes and blepharitis management, with the intensity of treatment adjusted based on severity and response.