What is the treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

Warm compresses for 10-15 minutes, 3-4 times daily, combined with eyelid hygiene and gentle massage is the first-line treatment for styes, with topical antibiotics like erythromycin ointment added for signs of infection. 1

First-Line Treatment Approach

The management of styes follows a stepwise approach:

1. Conservative measures (first-line):

   • Apply warm compresses to the affected eyelid for 10-15 minutes, 3-4 times daily
   • This helps liquefy thickened sebum, promotes drainage, and reduces inflammation
   • Perform gentle eyelid cleansing using a clean pad, cotton ball, cotton swab, or clean fingertip
   • Include vertical eyelid massage to express meibomian gland secretions 1

2. Topical antibiotics (second-line):

   • Add topical antibiotic ointment (bacitracin or erythromycin) when there are signs of blepharitis or risk of secondary infection
   • Apply to the eyelid margin until resolution (typically 7-10 days) 1

3. Advanced treatment options (third-line):

   • Consider combination antibiotic/steroid topical treatment for moderate to severe cases
   • For persistent (>2 months) or large chalazia, intralesional steroid injection or incision and curettage may be necessary 1

Oral Antibiotics for Severe or Recurrent Cases

For severe or recurrent styes, oral antibiotics may be considered:

• First-line oral options:

  • Dicloxacillin: 500 mg four times daily (adults)
  • Cephalexin: 500 mg four times daily (adults) or 25-50 mg/kg/day in 4 divided doses (children) 1

• Alternative oral options:

  • Clindamycin: 300-450 mg three times daily (adults) or 10-20 mg/kg/day in 3 divided doses (children)
  • For suspected MRSA: TMP-SMX or tetracyclines (doxycycline or minocycline) 1

• Special populations:

  • For children or women of childbearing age who cannot take tetracyclines: Oral erythromycin (30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks for children) 1

Important Safety Considerations

• Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years
• Oral azithromycin may lead to serious heart rhythm irregularities
• Rifampin-based combinations require monitoring for resistance development 1

Prevention of Recurrence

To prevent stye recurrence:

• Maintain good eyelid hygiene
• Remove eye makeup completely
• Treat underlying conditions
• Discontinue contact lens wear until symptoms resolve
• Keep draining wounds covered with clean, dry bandages
• Focus cleaning on high-touch surfaces that may contact bare skin 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

Treatment Monitoring

• Reassess initial treatment after 2-4 weeks
• Provide patient education on the potentially chronic nature of the condition
• Most styes resolve within 7-10 days with appropriate treatment 1

Evidence Limitations

It's worth noting that despite these recommendations from the American Academy of Ophthalmology, systematic reviews have found limited high-quality evidence for non-surgical interventions for hordeolum. Cochrane reviews in 2013 and 2017 found no randomized controlled trials specifically addressing acute internal hordeolum treatment 2, 3. However, clinical experience and expert consensus support the treatment algorithm outlined above.