What is the treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

Start with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing using diluted baby shampoo or commercial eyelid cleaners—this conservative approach is first-line therapy and resolves most cases without antibiotics. 1, 2, 3

First-Line Conservative Management

Warm Compress Technique

• Apply warm compresses for 5-10 minutes to soften debris and warm meibomian secretions 1, 3
• Perform 3-4 times daily (or at minimum once or twice daily at convenient times) 1, 2
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 2, 3
• Ensure water is warm but not hot enough to burn the skin 2, 3

Eyelid Cleansing After Warm Compresses

• Gently rub the base of the eyelashes using diluted baby shampoo or commercial eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 3
• Perform once or twice daily to remove debris and inflammatory material 1
• Apply gentle vertical massage of the eyelid to help express secretions from the affected gland 1, 2
• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used 2, 3

Critical Safety Considerations

• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleaning 2, 3
• Patients with advanced glaucoma should avoid aggressive eyelid pressure as it may increase intraocular pressure 2, 3
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or skill 2, 3

Second-Line Treatment (If No Improvement After 2-4 Weeks)

Topical Antibiotics

• Apply bacitracin or erythromycin ointment to the eyelid margins one or more times daily (or at bedtime) for a few weeks 1, 2, 3
• Mupirocin 2% topical ointment is an alternative option 1
• The frequency and duration should be guided by severity and response to treatment 1, 3
• Consider using different antibiotics intermittently to prevent resistant organisms 1
• Long-term antibiotic treatment may result in development of resistant organisms 2, 3

Third-Line Treatment for Persistent or Severe Cases

Oral Antibiotics

• Consider oral doxycycline, minocycline, or tetracycline for meibomian gland dysfunction not adequately controlled by topical treatments 1, 2
• Tetracyclines are contraindicated in pregnancy and children under 8 years 1, 2
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 1, 2

Surgical Intervention

• For worsening upper eyelid hordeolum, incision and drainage is recommended as the next step 1
• If signs of spreading infection are present, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA 1
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 1

Topical Corticosteroids

• May provide symptomatic relief but should be used with caution and under ophthalmological supervision 1
• In patients with advanced glaucoma, use steroid-containing drops with caution and monitor intraocular pressure closely 1

When to Refer to Ophthalmology

• If no improvement after incision and drainage plus appropriate antibiotic therapy 1
• If signs of orbital cellulitis or systemic illness develop 1
• If the stye is in a difficult-to-treat location such as the inner eyelid 1
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location—consider biopsy to exclude carcinoma 2, 3

Long-Term Management Expectations

• Patients should be advised that warm compress and eyelid cleansing treatment may be required long-term, as symptoms often recur when treatment is discontinued 1, 2, 3
• A schedule of regularly performed eyelid cleansing, daily or several times weekly, often reduces symptoms of chronic blepharitis 2

Important Clinical Pitfall

The Cochrane systematic reviews found no randomized controlled trials supporting any specific non-surgical intervention for acute internal hordeolum, highlighting that current recommendations are based primarily on expert consensus and observational data rather than high-quality evidence 4, 5. Despite this limitation, the American Academy of Ophthalmology guidelines consistently recommend the conservative approach outlined above as standard practice 1, 2, 3.