What is the treatment for a sty (hordeolum) in pediatric patients with swelling around the eye without an abscess?

Treatment of Hordeolum (Sty) in Pediatric Patients Without Abscess

The first-line treatment for a hordeolum (sty) in pediatric patients without abscess is warm compresses applied to the affected eyelid 4-6 times daily for 10-15 minutes, combined with gentle eyelid cleansing and massage. 1

Initial Management

• Apply warm compresses to the affected eyelid for 10-15 minutes, 4-6 times daily to promote drainage and resolution 1
• Perform gentle eyelid cleansing using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1
• Vertical eyelid massage can help express meibomian secretions, while rubbing the eyelid margins from side to side removes crusting from the eyelashes 1
• Instruct patients/caregivers to avoid using compresses that are too hot to prevent burns to the skin 1

Pharmacological Treatment

For Mild Cases:

• Topical antibiotic ointment such as erythromycin or bacitracin applied to the eyelid margins once or more times daily or at bedtime for a few weeks 1, 2
• For erythromycin ophthalmic ointment, apply approximately 1 cm in length directly to the affected eye(s) up to six times daily, depending on the severity of the infection 2

For Moderate to Severe Cases:

• If symptoms persist despite warm compresses and topical antibiotics, consider oral antibiotics 1
• For children under 8 years of age, oral erythromycin (30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks) or azithromycin (5 mg/kg daily for 2 months) may be used 1
• For children 8 years and older, doxycycline or minocycline can be considered, but tetracyclines should not be used in children under 8 years due to the risk of teeth staining 1

Special Considerations

• If MRSA is suspected (based on local prevalence or previous history), consider obtaining cultures and using appropriate antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMX) 1
• For recurrent hordeola, consider evaluation for underlying conditions such as blepharitis, rosacea, or seborrheic dermatitis 1
• Instruct patients on proper hygiene measures to prevent recurrence:
  • Keep hands clean with regular washing using soap and water 1
  • Avoid sharing personal items like towels or makeup 1
  • Replace eye makeup regularly 1

When to Refer/Consider Additional Treatment

• If no improvement after 48-72 hours of conservative treatment 3, 4
• If spreading cellulitis or orbital involvement is suspected 5
• If recurrent hordeola occur despite appropriate treatment 1
• For children with multiple or recurrent hordeola, consider evaluation for underlying systemic conditions 1

Evidence Quality and Limitations

• There is a lack of high-quality randomized controlled trials specifically for internal hordeolum treatment in pediatric patients 3, 4
• Most treatment recommendations are based on clinical experience and expert consensus rather than strong evidence 3
• A Cochrane review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeola 3, 4

Common Pitfalls

• Failure to distinguish between a hordeolum and a chalazion, which may require different management approaches 1
• Using tetracyclines in children under 8 years of age, which can cause permanent teeth staining 1
• Inadequate duration or frequency of warm compress application 1
• Premature discontinuation of treatment, which may lead to recurrence 1