What is the recommended treatment for a recurrent sty (hordeolum)?

Treatment for Recurrent Sty (Hordeolum)

For recurrent stys (hordeola), a combination of warm compresses, topical antibiotics, and decolonization strategies is recommended, with mupirocin nasal ointment being the most effective intervention for preventing recurrences. 1

Initial Management of Acute Sty

• Apply warm compresses to the affected eyelid for 5-10 minutes several times daily to promote drainage and resolution 1
• For minor infections, topical antibiotics such as mupirocin 2% ointment can be applied to the affected area 1
• Keep the affected area clean and avoid touching or squeezing the sty 1
• For more severe cases with significant inflammation or systemic symptoms, oral antibiotics may be necessary 1

Antibiotic Options for Moderate to Severe Cases

• Clindamycin alone is recommended if coverage for both MRSA and streptococci is desired 1
• Trimethoprim-sulfamethoxazole (TMP-SMX) or a tetracycline (doxycycline or minocycline) in combination with a beta-lactam (e.g., amoxicillin) is an alternative option 1
• Tetracyclines should not be used in children under 8 years of age 1

Management of Recurrent Stys

Decolonization Strategies

For patients with recurrent stys despite optimizing wound care and hygiene measures, decolonization should be considered 1:

1. Nasal decolonization:

   • Mupirocin 2% ointment applied inside both nostrils twice daily for 5-10 days 1

2. Comprehensive decolonization:

   • Nasal mupirocin twice daily for 5-10 days PLUS
   • Topical body decolonization with chlorhexidine skin antiseptic solution for 5-14 days OR
   • Dilute bleach baths (1 teaspoon per gallon of water or ¼ cup per ¼ tub) for 15 minutes twice weekly for up to 3 months 1

Hygiene Measures

• Keep affected areas covered with clean, dry bandages 1
• Maintain good personal hygiene with regular bathing and hand cleaning with soap and water or alcohol-based sanitizer 1
• Avoid reusing or sharing personal items (e.g., towels, washcloths, makeup) that have contacted infected skin 1
• Focus cleaning efforts on high-touch surfaces that may contact bare skin 1
• Use appropriate cleaners or detergents for routine surface cleaning 1

Special Considerations

• Cultures are generally not needed for typical cases but may be considered for recurrent infections to guide antibiotic therapy 1
• Screening cultures prior to decolonization are not routinely recommended if at least one of the prior infections was documented as due to MRSA 1
• Surveillance cultures following decolonization are not routinely recommended in the absence of active infection 1
• For persistent or atypical lesions, consider evaluation for underlying conditions causing meibomian gland dysfunction or chronic blepharitis 2

Common Pitfalls and Caveats

• Failure to address colonization in recurrent cases can lead to continued infections 1
• Incomplete decolonization regimens may not effectively prevent recurrences 1
• Not evaluating household contacts in cases of recurrent infection may miss ongoing transmission 1
• Persistent or atypical lesions should be evaluated to rule out malignancy 2
• While acupuncture has shown some promise in treating acute hordeolum in limited studies, the evidence is of low to very low certainty 3