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

Recommended Treatment for a Stye (Hordeolum)

The first-line treatment for a stye (hordeolum) is warm compresses applied to the affected eyelid 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
  • Technique: Use a clean washcloth soaked in warm water (not hot enough to burn)
  • Place compress close to but not touching the eyelid to avoid distorting corneal shape 2
  • Continue treatment until the stye resolves or drains spontaneously
• Eyelid hygiene: Clean eyelid margins with mild soap or commercial eyelid cleanser
• Gentle massage: After applying warm compresses, gently massage the affected area to help express the blocked gland

Second-Line Treatment

• Topical antibiotics: For signs of infection or risk of secondary infection
  • Bacitracin or erythromycin ointment applied to the affected area 1-3 times daily 1, 3
  • For adults and children over 2 years: Apply a small amount (equal to the surface area of fingertip) 3
  • For children under 2 years: Consult a doctor before use 3

Third-Line Treatment

• Combination antibiotic/steroid topical treatment: For moderate to severe cases
  • Topical loteprednol etabonate/tobramycin has shown 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

The American Academy of Ophthalmology recommends a step-wise approach to treating styes, with warm compresses, eyelid hygiene, and gentle massage as first-line treatment 1. Despite this strong recommendation, Cochrane reviews from 2013 and 2017 found no randomized controlled trials evaluating non-surgical interventions for internal hordeola 4, 5, highlighting a gap between clinical practice and high-quality evidence.

Warm compresses have physiological support - research shows they increase tear film lipid layer thickness by more than 80% after just 5 minutes of application in patients with meibomian gland dysfunction 6. This helps melt the blocked secretions in the affected gland.

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 1

For recurrent styes, consider:

• 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

Refer to an ophthalmologist if the patient experiences:

• 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