What is the medical management of a stye (hordeolum)?

Medical Management of a Stye (Hordeolum)

The primary treatment for a stye is the application of warm compresses for 10-15 minutes, 3-4 times daily, combined with gentle eyelid massage and proper eyelid hygiene, with topical antibiotics reserved for cases showing signs of infection or at risk of secondary infection. 1

First-Line Treatment

• Warm compresses: Apply directly to the affected eyelid for 10-15 minutes, 3-4 times daily
  • Helps promote drainage of the blocked gland
  • Increases blood circulation to the area
  • Aids in resolution of the inflammation
• Eyelid hygiene: Clean eyelids with mild soap or commercial eyelid cleanser
• Gentle massage: After warm compress application, gently massage the affected area to promote drainage

Second-Line Treatment

Add topical antibiotics when:

• Signs of blepharitis are present
• Risk of secondary infection exists
• No improvement after 48-72 hours of warm compresses

Recommended topical antibiotics:

• Bacitracin ointment: Apply a small amount (equal to the tip of a finger) to the affected area 1-3 times daily 2
• Erythromycin ophthalmic ointment: Apply approximately 1 cm in length directly to the affected eye(s) up to six times daily, depending on severity 1

Third-Line Treatment

For moderate to severe cases that don't respond to initial therapy:

• Consider combination antibiotic/steroid topical treatment 1
• For persistent or recurrent infections, oral antibiotics may be considered:
  • Doxycycline (not for children under 8 years) 3, 1
  • Azithromycin (with caution due to potential cardiac risks) 1

Fourth-Line Treatment

For persistent (>2 months) or large styes:

• Consider referral for intralesional steroid injection
• Incision and drainage may be necessary 1

Special Considerations

Pediatric Patients

• For children under 2 years: Consult a doctor before applying topical antibiotics 2
• Tetracyclines (including doxycycline) should not be used in children under 8 years of age 3
• For pediatric patients requiring systemic antibiotics, erythromycin at 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks may be used 1

When to Refer to a Specialist

Refer to an ophthalmologist when:

• Visual changes occur
• Corneal involvement is suspected
• Severe eyelid swelling unresponsive to initial treatment
• Suspected malignancy
• Cicatricial changes in the conjunctiva 1

Prevention of Recurrence

• Maintain good eyelid hygiene
• Complete removal of eye makeup before sleeping
• Treat underlying conditions (seborrheic dermatitis, rosacea, eczema, thyroid dysfunction)
• Discontinue contact lens wear until symptoms resolve 1

Important Cautions

• Avoid squeezing or manipulating the stye as this may spread infection
• Patients should be educated about the potentially chronic nature of the condition
• Follow-up assessment after 2-4 weeks is recommended to evaluate treatment response
• Consider biopsy for cases with marked asymmetry between eyes, resistance to standard therapy, unifocal recurrent chalazia, loss of normal eyelid margin anatomy, or focal lash loss 1

Despite the common occurrence of styes, there is limited high-quality evidence for non-surgical interventions. A Cochrane review found no randomized controlled trials specifically addressing the effectiveness of non-surgical treatments for acute internal hordeolum 4, 5.