What is the treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

Warm compresses applied for 5-10 minutes, 3-4 times daily, combined with eyelid hygiene using diluted baby shampoo or commercial eyelid cleaners, is the first-line treatment for styes. 1, 2, 3

First-Line Conservative Management

The cornerstone of stye treatment is non-pharmacologic intervention:

• Apply warm compresses to the affected eyelid for 5-10 minutes to soften debris, warm meibomian secretions, and promote drainage 1, 2, 3
• Perform warm compresses 3-4 times daily for optimal effect 2
• Use water that is warm but not hot enough to burn the skin; options include hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1, 3
• Follow warm compresses immediately with gentle eyelid cleansing and massage to express the contents of the affected gland 1, 2, 3
• Clean the eyelid 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, 3
• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used for treatment 1, 3
• Perform eyelid cleansing once or twice daily 1, 2, 3

Important Safety Considerations for Conservative Treatment

• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 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, 3

Second-Line Treatment: Topical Antibiotics

If there is no improvement after 2-4 weeks of conservative management, or for moderate to severe cases:

• Topical antibiotic ointment such as bacitracin or erythromycin applied 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 2

Caution with Antibiotic Use

• Long-term antibiotic treatment may result in development of resistant organisms 1, 3
• Consider using different antibiotics intermittently to prevent resistance 2

Third-Line Treatment: Oral Antibiotics

For persistent or severe cases with meibomian gland dysfunction not controlled by topical treatments:

• Oral tetracyclines (doxycycline, minocycline, or tetracycline) may be considered 1, 2
• Contraindicated in pregnancy and children under 8 years of age 1, 2
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 1, 2

Surgical Management

For worsening or non-responsive styes:

• Incision and drainage is recommended as the next step for worsening upper eyelid hordeolum 2
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 2
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 2

When to Refer to Ophthalmology

• No improvement after incision and drainage plus appropriate antibiotic therapy 2
• Signs of orbital cellulitis or systemic illness (immediate referral required) 2
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude carcinoma 1, 3
• Stye in an area difficult to treat, such as the inner eyelid 2

Long-Term Management and Prevention

• 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
• Regular eyelid hygiene, especially for those prone to styes or with chronic blepharitis 1
• Proper contact lens hygiene and avoiding wearing contact lenses longer than recommended 1
• Avoid sharing eye makeup and replace eye makeup regularly 1
• For recurrent styes, daily eyelid cleansing may help prevent recurrence 1

Common Pitfall

The most common mistake is prescribing topical antibiotics as first-line treatment. The evidence clearly shows that warm compresses and eyelid hygiene should be tried first, with antibiotics reserved for cases that don't respond to conservative management after 2-4 weeks or for moderate to severe presentations. 1, 2, 3