Treatment of Styes (Hordeolum)
The recommended first-line treatment for a stye is warm compresses applied for 10-15 minutes, 3-4 times daily, combined with gentle eyelid hygiene and massage. 1
Treatment Algorithm
First-Line Treatment
- Warm compresses: Apply for 10-15 minutes, 3-4 times daily
- Helps soften adherent scales, discharge, and warm meibomian secretions
- Can be applied using washcloths, though hard-boiled eggs or specialized heat-retention devices may provide better heat retention 2
- Eyelid hygiene: Clean eyelid margins with mild soap or commercial eyelid cleanser
- Gentle massage: After warm compresses, apply gentle pressure to help express the contents of the affected gland
Second-Line Treatment
- Topical antibiotics: Add when signs of infection are present or to prevent secondary infection
- Bacitracin or erythromycin ointment applied to eyelid margins once or more daily
- Should be used intermittently to prevent resistant organisms
Third-Line Treatment
- Combination antibiotic/steroid topical treatment: Consider for moderate to severe cases with significant inflammation
- Short-term use only, with monitoring for steroid-related complications
Fourth-Line Treatment
- Intralesional steroid injection or incision and curettage: For persistent (>2 months) or large styes that develop into chalazia
Special Considerations
Types of Styes
- External hordeolum (stye): Infection of the glands of Zeis or Moll at the eyelid margin
- Internal hordeolum: Infection of meibomian glands deeper in the eyelid
Patient Education Points
- Styes are often recurrent and may require ongoing management
- Avoid eye makeup during active infection
- Discontinue contact lens wear until symptoms resolve 1
- Replace contact lenses and case after resolution
When to Refer
- Persistent styes lasting >2 months
- Development into chalazia
- Aggressive infections with signs of systemic toxicity
- Recurrent styes that don't respond to treatment
Evidence Quality and Limitations
The American Academy of Ophthalmology recommends warm compresses and eyelid hygiene as first-line therapy for all patients with blepharitis and styes 1. However, it's important to note that multiple Cochrane reviews (2010,2013,2017) found no randomized controlled trials specifically evaluating non-surgical interventions for internal hordeolum 3, 4, 5. This highlights a significant gap in high-quality evidence for stye treatment.
One small randomized controlled trial from 2013 compared ear-apex blood-letting (a traditional therapy) to conventional medication for external styes and found the traditional approach more effective 6, but this is not a mainstream treatment in most medical settings.
Common Pitfalls to Avoid
- Premature incision: Avoid attempting to "pop" or drain a stye at home
- Inadequate warm compress application: Many patients apply compresses for too short a duration
- Discontinuing treatment too early: Continue treatment until complete resolution to prevent recurrence
- Overuse of antibiotics: Use topical antibiotics only when indicated to prevent antibiotic resistance
- Ignoring underlying conditions: Patients with rosacea are more prone to developing styes and may require more aggressive management 1
Despite limited high-quality evidence, warm compresses, eyelid hygiene, and gentle massage remain the cornerstone of stye treatment based on clinical experience and expert consensus.