What is the treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

First-Line Treatment: Conservative Management

Warm compresses combined with eyelid hygiene are the definitive first-line treatment for styes, with topical antibiotics reserved only for cases that fail to respond to conservative measures. 1, 2, 3

Warm Compress Technique

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften debris, warm meibomian secretions, and promote drainage 3
• Use water that is warm but not hot enough to burn the skin 1, 2
• For sustained warmth, options include hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in the microwave 1

Eyelid Hygiene Protocol

• Immediately after warm compresses, perform gentle eyelid cleansing and massage to express the contents of the affected gland 1, 2
• Clean the eyelid by gently rubbing the base of the eyelashes using either diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 2, 3
• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used for treatment 1, 2
• For posterior blepharitis/meibomian gland involvement, perform gentle vertical massage of the eyelid to help express secretions 3

Second-Line Treatment: Topical Antibiotics

If no improvement occurs after 2-4 weeks of conservative management, topical antibiotic ointments are indicated 1, 3:

• Apply bacitracin or erythromycin ointment to the eyelid margins once or more times daily (or at bedtime) for a few weeks 1, 2, 3
• Topical antibiotics provide symptomatic relief and decrease bacteria from the eyelid margin 1, 2
• The frequency and duration should be guided by severity and response to treatment 1, 2, 3
• Mupirocin 2% topical ointment is an alternative option for minor skin infections 3

Third-Line Treatment: Systemic Therapy

For persistent or severe cases not controlled by topical measures 1, 3:

• Oral tetracyclines (doxycycline, minocycline, or tetracycline) may be helpful for patients with meibomian gland dysfunction whose symptoms are not adequately controlled 1, 3
• For women of childbearing age and children under 8 years, use oral erythromycin or azithromycin instead of tetracyclines 1, 3

Surgical Intervention

For worsening styes despite appropriate medical management, incision and drainage is the next step, along with consideration of oral antibiotics if there are signs of spreading infection 3:

• If signs of spreading infection develop, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 3
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 3

Critical Safety Considerations and Pitfalls

High-Risk Populations

• Patients with neurotrophic corneas need proper counseling to avoid injury to corneal epithelium during eyelid cleansing 1, 2, 3
• Patients with advanced glaucoma should avoid aggressive pressure on the eyelids as it may increase intraocular pressure 1, 2, 3
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or skill to perform the task safely 1, 2

Red Flags Requiring Referral

• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 1, 2
• If there are signs of orbital cellulitis or systemic illness, immediate referral to an ophthalmologist is necessary 3
• If no improvement occurs after incision and drainage plus appropriate antibiotic therapy, referral to an ophthalmologist is recommended 3

Antibiotic Resistance Concerns

• Long-term antibiotic treatment may result in the development of resistant organisms 1, 2, 3
• Consider using different antibiotics intermittently to prevent development of resistant organisms 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 1
• For recurrent styes, daily eyelid cleansing may help prevent recurrence 1

Evidence Quality Note

The Cochrane systematic reviews found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, meaning current recommendations are based on expert consensus and observational data rather than high-quality trial evidence 4, 5. Despite this limitation, the conservative approach of warm compresses and eyelid hygiene remains the standard of care given its safety profile and clinical experience supporting its effectiveness.