What is the recommended treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

Warm compresses applied for 5-10 minutes once or twice daily, followed by gentle eyelid cleansing and massage, is the first-line treatment for stye, with topical antibiotics reserved for moderate to severe cases that fail conservative management. 1, 2

First-Line Conservative Management

Warm Compress Application:

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

Eyelid Cleansing and Massage:

• After warm compresses, perform gentle eyelid cleansing and massage to express the contents of the affected gland 1, 2
• Gently rub the base of the eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 2
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and can be used 1, 2

Second-Line Antibiotic Therapy

When to Add Topical Antibiotics:

• For moderate to severe cases that don't respond to warm compresses and eyelid hygiene alone 1, 2
• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins once or more daily or at bedtime for a few weeks 1, 2
• 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

Severe or Recurrent Cases

Oral Antibiotics:

• For patients with meibomian gland dysfunction whose symptoms are not adequately controlled by eyelid cleansing, consider oral tetracyclines (doxycycline, minocycline, or tetracycline) 2
• For women of childbearing age and children, use oral erythromycin or azithromycin instead of tetracyclines 2

Critical Safety Considerations

Special Populations:

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

Red Flags Requiring Biopsy:

• If a stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 1, 2

Long-Term Management

Treatment Duration:

• 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
• Long-term antibiotic treatment may result in the development of resistant organisms 1, 2
• Follow-up should be based on the severity of the condition and response to treatment 1, 2

Evidence Quality Note

The American Academy of Ophthalmology guidelines provide the strongest recommendations for this stepwise approach 1, 2. A Cochrane review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting that current treatment recommendations are based on clinical experience rather than high-quality trial evidence 3. Despite the lack of RCT evidence, the conservative approach of warm compresses and eyelid hygiene remains the standard of care given its safety profile and clinical effectiveness 1, 2.