How to manage a sty (hordeolum)?

Management of Sty (Hordeolum)

Warm compresses applied to the affected eyelid for 5-10 minutes several times daily is the most effective first-line treatment for stys (hordeola). 1

First-Line Management

• Apply warm compresses to the affected eyelid for 5-10 minutes, 1-2 times daily to soften debris and warm meibomian secretions 1
• Follow warm compresses with gentle eyelid cleansing and massage to help express the contents of the affected gland 1
• Use either diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip for cleansing 1
• Eye cleaners with hypochlorous acid at 0.01% can be used for their antimicrobial effect 1

Technique Considerations

• Use water that is warm but not hot enough to burn the skin 1
• Options for sustained warmth include hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in the microwave 1
• Avoid touching or squeezing the sty to prevent spreading the infection 2

Second-Line Treatment

• For minor infections that don't respond to warm compresses, apply topical antibiotics such as mupirocin 2% ointment to the affected area 2
• Topical antibiotics like bacitracin or erythromycin can be applied to the eyelid margins 1-4 times daily or at bedtime for symptomatic relief 1

For Moderate to Severe Cases

• If significant inflammation, pain, or systemic symptoms are present, oral antibiotics may be necessary 2
• Clindamycin is recommended if coverage for both MRSA and streptococci is desired 2
• Trimethoprim-sulfamethoxazole (TMP-SMX) or a tetracycline (doxycycline or minocycline) in combination with a beta-lactam (e.g., amoxicillin) is an alternative option 2
• Tetracyclines should not be used in children under 8 years of age 2, 3

Management of Recurrent Stys

• Consider decolonization strategies for patients with recurrent stys despite optimizing wound care and hygiene measures 2
• Apply mupirocin 2% ointment inside both nostrils twice daily for 5-10 days for nasal decolonization 2
• For comprehensive decolonization, combine nasal mupirocin with topical body decolonization using chlorhexidine skin antiseptic solution and dilute bleach baths 2

Hygiene Measures for Prevention

• Maintain good personal hygiene with regular bathing and hand cleaning with soap and water or alcohol-based sanitizer 2
• Avoid reusing or sharing personal items that have contacted infected skin 2, 3
• Keep draining wounds covered with clean, dry bandages 3

Special Considerations

• If a sty is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 1
• Cultures are generally not needed for typical cases but may be considered for recurrent infections to guide antibiotic therapy 2
• Evaluate household contacts for evidence of S. aureus infection in cases of recurrent stys 3

Common Pitfalls

• Failure to address colonization in recurrent cases can lead to continued infections 2
• Incomplete decolonization regimens may not effectively prevent recurrences 2
• Long-term antibiotic treatment may result in the development of resistant organisms 1
• Not evaluating household contacts in cases of recurrent infection may miss ongoing transmission 2, 3