What is the recommended medication for hordeolum (stye)?

Treatment of Hordeolum (Stye)

Most hordeola resolve spontaneously without specific medication, but warm compresses remain the cornerstone of conservative management, with topical antibiotics reserved for cases with significant surrounding inflammation or when conservative measures fail. 1, 2

Initial Conservative Management

• Warm compresses applied 3-4 times daily for 10-15 minutes are the primary treatment, promoting spontaneous drainage and resolution 1, 2
• Most hordeola drain spontaneously within approximately one week without requiring medication 1, 2
• Lid hygiene and gentle massage may facilitate drainage 3

When to Consider Antibiotic Therapy

Topical Antibiotics

• Consider topical antibiotics when there is significant eyelid inflammation, surrounding cellulitis, or failure of conservative management 3
• Azithromycin ophthalmic solution (1.5%) has demonstrated efficacy for internal hordeolum, dosed twice daily for 2 days, then once daily for 12 days 4
• Other topical antibiotic options include erythromycin or bacitracin ointment applied to the eyelid margin 3
• Topical antibiotics target the typical causative organism, Staphylococcus species 1, 2

Systemic Antibiotics

• Oral antibiotics are indicated when there is spreading cellulitis, multiple recurrent hordeola, or systemic signs of infection 3
• Consider oral anti-staphylococcal antibiotics (e.g., dicloxacillin, cephalexin) for severe cases 3
• Patients with multiple recurrent hordeola warrant evaluation for underlying conditions such as blepharitis, rosacea, or immunodeficiency 3, 5

Evidence Limitations and Clinical Approach

Key Evidence Gaps

• No randomized controlled trials have established the effectiveness of any non-surgical intervention for acute internal hordeolum 1, 2
• The evidence base consists primarily of observational studies and clinical experience rather than high-quality trials 1, 2
• Most treatment recommendations are based on expert consensus and pathophysiologic rationale 3

Practical Algorithm

1. Start with warm compresses for all patients - this is safe, low-cost, and often effective 1, 2
2. Add topical antibiotics if:
   • Significant surrounding inflammation present 3
   • No improvement after 48-72 hours of warm compresses 3
   • Patient has underlying blepharitis 3
3. Consider oral antibiotics if:
   • Spreading cellulitis develops 3
   • Multiple or recurrent lesions 3, 5
   • Systemic symptoms present 3

Important Clinical Considerations

Associated Conditions

• Hordeola are commonly associated with chronic blepharitis and meibomian gland dysfunction, which should be addressed to prevent recurrence 3
• Recurrent hordeola may indicate underlying seborrheic dermatitis, rosacea, or rarely, immunodeficiency 3, 5

When Surgical Intervention is Needed

• If an internal hordeolum fails to resolve with conservative management, incision and drainage may be required 3
• Chronic unresolved internal hordeolum can evolve into a chalazion, requiring different management 1, 2

Common Pitfalls

• Avoid prescribing antibiotics reflexively - most cases resolve with warm compresses alone 1, 2
• Do not confuse internal hordeolum with chalazion - chalazia are chronic granulomatous inflammations requiring different treatment approaches 1, 2
• Screen for underlying blepharitis in patients with recurrent hordeola, as treating the underlying condition prevents recurrence 3