What is the treatment for a stye (hordeolum) on the inner lower eyelid?

Treatment for Inner Lower Eyelid Stye (Hordeolum)

Start with warm compresses applied to the affected eyelid for 5-10 minutes, once or twice daily, combined with gentle eyelid cleansing—this is the cornerstone of treatment for styes on the inner lower eyelid. 1, 2

First-Line Conservative Management

Warm Compress Technique:

• Heat the compress to approximately 45°C (warm but not hot enough to burn the skin) 1, 3
• Apply for 5-10 minutes to soften adherent debris and warm the meibomian secretions 1, 2
• Reheat frequently during application—ideally every 2 minutes—to maintain therapeutic temperature, as compresses cool rapidly 3
• Optimize contact between the compress and the lower eyelid surface for maximum heat transfer 3
• Options include hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Perform once or twice daily at times convenient for the patient 1, 2

The evidence shows it takes at least 4 minutes to achieve an inner lower eyelid temperature ≥40°C, which is necessary for therapeutic effect, and up to 20-30 minutes of properly applied warm compresses may be needed for optimal results. 3

Eyelid Cleansing After Warm Compresses:

• Gently rub the base of the eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a cotton ball, cotton swab, or clean fingertip 1, 2
• Perform gentle massage to help express the contents of the affected gland 1
• Consider hypochlorous acid (0.01%) eyelid cleaners for their strong antimicrobial effects 1, 2

Second-Line: Topical Antibiotic Therapy

Add topical antibiotic ointment if the stye does not improve with conservative measures alone:

• Apply bacitracin or erythromycin ointment to the eyelid margins one or more times daily or at bedtime 1, 2
• Continue for a few weeks based on severity and response to treatment 1
• Topical antibiotics provide symptomatic relief and decrease bacterial load 1

Important Safety Considerations

Patient-Specific Precautions:

• Patients with advanced glaucoma should avoid applying excessive pressure on the eyelids during massage, as this may increase intraocular pressure 1, 2
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing 1
• Ensure the patient has adequate manual dexterity and judgment to perform eyelid cleansing safely 1

Treatment Duration and Expectations:

• Patients should understand that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued 1
• Most styes drain spontaneously and resolve within about a week 4, 5
• Follow-up should be based on symptom severity, with reassessment if symptoms worsen or fail to improve within 7-10 days 2

Red Flags Requiring Further Evaluation

Consider biopsy if the stye is:

• Markedly asymmetric
• Resistant to therapy
• Recurrent in the same location (to exclude carcinoma) 1

Evidence Quality Note

A Cochrane systematic review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, meaning current treatment recommendations are based on expert consensus and observational data rather than high-quality evidence. 4, 5 Despite this limitation, the warm compress and eyelid hygiene approach remains the standard of care recommended by the American Academy of Ophthalmology. 1, 2