Causes of Recurrent Stye (Hordeolum)
Nasal carriage of Staphylococcus aureus is the primary cause of recurrent styes, as the organism repeatedly auto-inoculates the eyelid margin from colonized nasal passages. 1
Primary Bacterial Colonization
- S. aureus nasal colonization is the most critical risk factor for recurrent skin and soft tissue infections, including hordeola, with the pathogen persistently residing in the nasopharynx and oropharynx 1, 2
- Both methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) can cause recurrent infections, with MRSA isolates becoming increasingly common 3, 1
- Ocular surface colonization with S. aureus serves as an additional reservoir for recurrent infection beyond nasal carriage 3, 2
- Recurrent bacterial keratitis and blepharitis are more likely caused by S. aureus compared to initial infections 3
Underlying Eyelid Conditions
- Chronic blepharitis creates an inflammatory environment that predisposes to recurrent hordeola, with periods of exacerbation and remission 3
- Meibomian gland dysfunction (MGD) leads to gland obstruction and stagnation of secretions, providing a nidus for bacterial overgrowth 3
- Rosacea is associated with recurrent chalazia and styes, particularly in children who may present with subtle facial signs but prominent ocular involvement 3
- Children with a history of styes have an increased risk of developing adult rosacea, suggesting a bidirectional relationship 3
Behavioral and Environmental Factors
- Sharing personal items such as towels, cosmetics, and pillowcases that have contacted infected areas perpetuates transmission and reinfection 1
- Inadequate hygiene practices allow persistent colonization and environmental contamination with S. aureus 1, 2
- Failure to decontaminate fomites (contaminated surfaces and objects) permits ongoing sources of reinfection 1
- Touching or manipulating the eyelids with contaminated hands facilitates auto-inoculation from colonized body sites 2
Host and Medication Factors
- Isotretinoin use for severe acne significantly increases S. aureus colonization of the conjunctiva and causes blepharitis, though discontinuation typically leads to improvement 3
- Dupilumab therapy for atopic dermatitis is associated with conjunctivitis, keratitis, and blepharitis in 32-55% of patients 3
- Metabolic syndrome components including increased waist circumference, elevated blood pressure, and dyslipidemia are associated with higher blepharitis risk 3
- Demodex mite infestation may play a contributory role, particularly in patients with rosacea and chronic blepharitis 3
Common Pitfalls in Understanding Recurrence
- Assuming recurrence represents antibiotic resistance when it actually reflects persistent colonization and inadequate decolonization strategies 1
- Treating only the acute infection without addressing underlying nasal and ocular surface colonization leads to continued recurrences 3, 2
- Failing to evaluate household contacts in cases of recurrent MRSA infection misses ongoing transmission dynamics 2
- Incomplete decolonization regimens that address only one colonization site (e.g., nasal only) may not effectively prevent recurrences 2