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

Treatment for Stye (Hordeolum)

Warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing, is the first-line treatment for styes, with topical antibiotics reserved for cases that fail to improve after 2-4 weeks of conservative management. 1, 2

First-Line Conservative Management

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 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, 3

Eyelid Hygiene:

• After warm compresses, perform gentle eyelid cleansing and massage to help express the contents of the affected gland 1, 2
• Clean the eyelid margin by gently rubbing 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 for treatment 1, 3
• For posterior blepharitis/meibomian gland involvement, perform gentle vertical massage of the eyelid to help express secretions 2

Second-Line Treatment (After 2-4 Weeks Without Improvement)

Topical Antibiotics:

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

Treatment for Severe, Persistent, or Worsening Cases

Surgical Intervention:

• For worsening hordeolum, incision and drainage is recommended as the next step in management 2
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist 2

Oral Antibiotics (for spreading infection):

• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 2
• For women of childbearing age and children under 8 years, use oral erythromycin or azithromycin instead of tetracyclines 2, 3
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 2

Important Safety Considerations and Pitfalls

Special Populations:

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

Red Flags Requiring Immediate Referral:

• If there are signs of orbital cellulitis or systemic illness, immediate referral to an ophthalmologist is necessary 2
• If a stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 1, 3

Long-term Management:

• 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
• Long-term antibiotic treatment may result in the development of resistant organisms 3
• Consider using different antibiotics intermittently to prevent development of resistant organisms 2