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

Stye (Hordeolum) Treatment

The recommended 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
  • Helps to increase blood flow to the area
  • Promotes drainage of the infected gland
  • Should be warm but not hot enough to burn the skin
• Eyelid hygiene: Clean the affected eyelid margin
• Gentle massage: After applying warm compresses, gently massage the affected area to help express the contents of the blocked gland

Second-Line Treatment

• Topical antibiotics: For signs of blepharitis or risk of secondary infection
  • Bacitracin or erythromycin ointment can be applied to the affected area 1-3 times daily 1, 2
  • For adults and children 2 years and older, apply a small amount (equal to the surface area of the tip of a finger) 2
  • For children under 2 years, consult a doctor before use 2

Third-Line Treatment

• Combination antibiotic/steroid topical treatment: For moderate to severe cases
  • Topical loteprednol etabonate/tobramycin shows efficacy with less risk of intraocular pressure rise 1

Fourth-Line Treatment

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

Evidence Quality and Considerations

It's important to note that despite the widespread recommendation of warm compresses and other non-surgical interventions, high-quality evidence supporting these treatments is limited. Cochrane reviews from 2013 and 2017 found no randomized controlled trials evaluating the effectiveness of non-surgical treatments for acute internal hordeolum 3, 4.

However, clinical experience and guideline recommendations from the American Academy of Ophthalmology strongly support the use of warm compresses as first-line therapy 1. Research has demonstrated that warm compresses can increase tear film lipid layer thickness by more than 80% after just 5 minutes of application in patients with meibomian gland dysfunction 5.

Application Technique for Warm Compresses

When applying warm compresses:

• Maintain a temperature of approximately 40°C (warm but not hot)
• Place the compress close to, but not touching, the eyelid to avoid distorting the corneal shape 6
• Apply for 10-15 minutes at a time
• Repeat 3-4 times daily

Prevention of Recurrence

To prevent stye recurrence:

• Practice good eyelid hygiene regularly
• Remove eye makeup completely
• Treat underlying conditions that may contribute to styes
• Discontinue contact lens wear until symptoms resolve 1

For recurrent styes, additional measures may include:

• Nasal decolonization with mupirocin twice daily for 5-10 days
• Topical body decolonization with chlorhexidine antiseptic solution for 5-14 days
• Dilute bleach baths (1 teaspoon per gallon of water, 15 minutes twice weekly for 3 months) 1

When to Refer to a Specialist

Referral to an ophthalmologist is recommended for:

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

Consider biopsy for cases with:

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