What is the treatment for multiple hordeolum (styes)?

Treatment for Multiple Styes (Hordeola)

The foundation of treatment for multiple styes is daily eyelid hygiene with warm compresses (10-15 minutes, 3-4 times daily) and gentle lid cleansing, combined with topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins once or more daily for 5-7 days. 1

First-Line Treatment

Warm Compresses

• Apply warm compresses for 10-15 minutes, 3-4 times daily 2, 1
• Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in the microwave
• This helps to liquefy the thickened sebum, promote drainage, and reduce inflammation

Eyelid Hygiene

• Gently cleanse the eyelid margins with:
  • Diluted baby shampoo
  • Commercially available eyelid cleaner
  • Hypochlorous acid 0.01% solution 1
• Use a clean pad, cotton ball, cotton swab, or clean fingertip
• Focus on removing crusting from eyelashes for anterior styes
• Include vertical eyelid massage to express meibomian gland secretions for posterior styes 1

Second-Line Treatment

Topical Antibiotics

• Apply bacitracin or erythromycin ointment to eyelid margins once or more daily for 5-7 days 2, 1
• These are effective for decreasing bacterial load on the eyelid margin
• Apply a small amount to the base of the eyelashes using a clean fingertip or cotton swab

Combination Treatments

• For moderate to severe cases, consider combination antibiotic/steroid topical treatment 1
• Short-term use of topical corticosteroids may be beneficial for marked inflammation 1

Third-Line Treatment

Oral Antibiotics

For persistent or severe cases, consider oral antibiotics:

• Dicloxacillin: 500 mg four times daily for adults 1
• Cephalexin: 500 mg four times daily for adults or 25-50 mg/kg/day in 4 divided doses for children 1
• Doxycycline, minocycline, or tetracycline for persistent posterior blepharitis/MGD 1

Important: Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years. They can cause photosensitization and gastrointestinal upset. 1

Special Considerations

For Persistent Styes

• If styes persist beyond 2 weeks or develop into chalazia, referral to an ophthalmologist is recommended 1
• Intralesional steroid injection or incision and curettage may be necessary for persistent chalazia 1

Prevention of Recurrence

• Continue regular eyelid hygiene even after resolution 2, 1
• Remove eye makeup completely 1
• Consider replacing contact lenses and cases after resolution 1
• Treat underlying conditions like blepharitis or meibomian gland dysfunction 2

Treatment Duration and Follow-up

• Initial treatment should be reassessed after 2-4 weeks 1
• Patient education is crucial regarding the potentially chronic nature of the condition 2, 1
• Blepharitis and recurrent styes often require long-term management with continued eyelid hygiene 2

When to Refer

Refer to an ophthalmologist for:

• Persistent styes (>2 weeks)
• Styes that develop into chalazia
• Suspected MRSA infections
• Visual changes
• Severe eyelid swelling extending beyond the eyelid margin
• Immunocompromised patients

Remember that multiple styes often indicate underlying chronic blepharitis that requires ongoing management beyond the acute treatment phase. The condition is typically chronic and may require long-term eyelid hygiene to prevent recurrence.