What is the treatment for a stye (hordeolum)?

Treatment for Stye (Hordeolum)

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

Treatment Algorithm

First-Line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
  • Most effective methods for heat retention:
    • Hard-boiled egg wrapped in cloth (placed near but not touching eyelid to avoid corneal distortion) 2
    • Commercial heat-generating products (Re-Heater) 3
    • Warm washcloth (less effective but accessible)
• Eyelid hygiene: Clean eyelid margins with mild soap or commercial lid scrubs
• Gentle massage: After warm compress to encourage drainage

Second-Line Treatment

• Topical antibiotics: Add if signs of infection are present
  • Bacitracin or erythromycin ointment applied to affected area 1

Third-Line Treatment

• Combination antibiotic/steroid topical treatment: For moderate to severe cases with significant inflammation 1

Fourth-Line Treatment

• Intralesional steroid injection or incision and curettage: For persistent styes (>2 months) or large chalazia 1

Important Clinical Considerations

Diagnostic Distinctions

• Internal hordeolum: Infection of meibomian gland (inside eyelid)
• External hordeolum (stye): Infection of sebaceous gland at eyelash base
• Chalazion: Chronic granulomatous inflammation of meibomian gland

When to Refer to an Ophthalmologist

• Visual changes
• Corneal involvement
• Severe eyelid swelling unresponsive to initial treatment
• Suspected malignancy (consider in cases of chronic or atypical presentation)
• Cicatricial changes in the conjunctiva 1

Warning Signs for Possible Malignancy

• Marked asymmetry between eyes
• Resistance to standard therapy
• Unifocal recurrent chalazia
• Loss of normal eyelid margin anatomy
• Focal lash loss (madarosis) 1

Prevention of Recurrence

• Practice good eyelid hygiene consistently
• Remove eye makeup completely before sleeping
• Treat underlying conditions (blepharitis, meibomian gland dysfunction)
• Discontinue contact lens wear until symptoms resolve 1

Evidence Quality Assessment

The evidence for stye treatment is primarily based on expert consensus and clinical guidelines rather than high-quality randomized controlled trials. Cochrane reviews in 2013 and 2017 found no randomized controlled trials specifically addressing internal hordeolum treatment 4, 5. Despite this lack of high-quality evidence, warm compresses remain the standard of care based on clinical experience and physiological principles.

One small randomized controlled trial from 2013 compared ear-apex blood-letting to medication for external styes, showing better outcomes with the blood-letting approach 6. However, this is not a widely adopted practice in Western medicine and requires further validation.

The recommendation for warm compresses is supported by studies on heat retention methods, with hard-boiled eggs and commercial heat-generating products showing superior heat retention compared to warm washcloths 3, 2.

Common Pitfalls to Avoid

• Squeezing or popping the stye: Can spread infection
• Applying excessive pressure during warm compresses: May distort corneal shape 2
• Discontinuing treatment prematurely: Continue treatment for 2-4 weeks and reassess
• Missing underlying conditions: Evaluate for meibomian gland dysfunction or blepharitis
• Overlooking potential malignancy: Consider sebaceous carcinoma in cases of chronic or atypical blepharitis 1