Treatment for Upper Eyelid Stye (Hordeolum)
The first-line treatment for an upper eyelid stye (hordeolum) is warm compresses applied for 10-15 minutes, 3-4 times daily, combined with gentle eyelid hygiene and massage to promote drainage. 1
Treatment Algorithm
First-Line Treatment
- Warm compresses: Apply for 10-15 minutes, 3-4 times daily
- Helps liquefy thickened sebum, promote drainage, and reduce inflammation
- The Re-Heater or hard-boiled egg methods provide better heat retention than warm washcloths 2
- Eyelid hygiene: Clean eyelid margins with a clean pad, cotton ball, cotton swab, or clean fingertip
- Focus on removing crusting from eyelashes
- Gentle massage: Apply vertical pressure to express meibomian gland secretions
Second-Line Treatment
- Topical antibiotics: Add if signs of blepharitis or risk of secondary infection exist
- Erythromycin or bacitracin ointment applied to the eyelid margin
- Continue until resolution, typically 7-10 days 1
Third-Line Treatment
- Combination antibiotic/steroid topical treatment: Consider for moderate to severe cases 1
Fourth-Line Treatment
- For persistent styes (>2 months) or those that develop into chalazia:
- Consider intralesional steroid injection
- Consider incision and curettage 1
Systemic Antibiotics (for severe or recurrent cases)
If the stye is severe, recurrent, or associated with significant surrounding cellulitis, 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)
- Clindamycin: 300-450 mg three times daily (adults) or 10-20 mg/kg/day in 3 divided doses (children) 1
For suspected MRSA:
- TMP-SMX or tetracyclines (doxycycline or minocycline) 1
- Note: Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years
Prevention of Recurrence
- Maintain good eyelid hygiene
- Remove eye makeup completely
- Treat underlying conditions (e.g., blepharitis)
- Discontinue contact lens wear until symptoms resolve 1
- 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
- Persistent styes (>2 weeks)
- Styes that develop into chalazia
- Suspected MRSA infections
- Visual changes
- Severe eyelid swelling
- Immunocompromised patients 1
Important Caveats
- Despite the widespread use of warm compresses and antibiotics for hordeolum treatment, high-quality evidence supporting these interventions is limited. A Cochrane review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum 3.
- Most styes are self-limiting and may resolve spontaneously within 7-10 days with drainage of the abscess 4.
- Chronic styes are typically caused by Staphylococcus aureus, with MRSA becoming increasingly common 1.
- Reassess initial treatment after 2-4 weeks and provide patient education on the potentially chronic nature of the condition 1.
By following this treatment approach, most styes will resolve within 1-2 weeks. The combination of warm compresses, eyelid hygiene, and topical antibiotics when indicated provides the most effective management strategy for upper eyelid styes.