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

Treatment of Styes (Hordeola)

The recommended first-line treatment for a stye (hordeolum) is warm compresses applied for 10-15 minutes, 3-4 times daily, combined with gentle eyelid cleansing and massage. 1

First-Line Management

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily to:

  • Liquefy thickened sebum
  • Promote drainage
  • Reduce inflammation 1

• Eyelid hygiene:

  • Gently cleanse eyelid margins with 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 blepharitis 1

Second-Line Treatment

• Topical antibiotics: Apply bacitracin or erythromycin ointment to eyelid margins once or more daily for 5-7 days 1
  • For adults and children 2 years and older: Apply a small amount (equal to the surface area of fingertip) to the affected area 1-3 times daily 2
  • For children under 2 years: Consult a doctor 2

Third-Line Treatment

• Combination antibiotic/steroid topical treatment for moderate to severe cases 1
• Short-term topical corticosteroids may be beneficial for marked inflammation 1

When to Consider Oral Antibiotics

For severe cases, consider oral antibiotics such as:

• Dicloxacillin: 500 mg four times daily for adults
• Cephalexin: 500 mg four times daily for adults or 25-50 mg/kg/day in 4 divided doses for children
• Clindamycin: 300-450 mg three times daily for adults or 10-20 mg/kg/day in 3 divided doses for children 1

Prevention of Recurrence

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

When to Refer to an Ophthalmologist

Refer to an ophthalmologist for:

• Persistent styes (>2 weeks)
• Styes that develop into chalazia
• Suspected MRSA infections
• Visual changes
• Severe eyelid swelling
• Immunocompromised patients 1

Important Caveats

1. Limited evidence: Despite common use, there is a lack of high-quality randomized controlled trials specifically evaluating treatments for acute internal hordeola 3, 4

2. Medication precautions:

   • Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years
   • Oral azithromycin may lead to serious heart rhythm irregularities 1

3. Special considerations:

   • Ensure patients have adequate manual dexterity to perform eyelid hygiene safely
   • Patients with advanced glaucoma should avoid aggressive lid pressure
   • Patients with neurotrophic corneas need special care to avoid corneal epithelial injury 1

Treatment Algorithm

1. Initial (Days 1-7): Warm compresses + eyelid hygiene + gentle massage
2. If no improvement (Days 3-7): Add topical antibiotic (bacitracin or erythromycin ointment)
3. For moderate to severe cases: Consider combination antibiotic/steroid topical treatment
4. For persistent cases (>2 weeks): Refer to ophthalmologist for possible intralesional steroid injection or incision and curettage