What are the treatment options for a bump on the bottom eyelid?

Treatment of Eyelid Bump

For a bump on the bottom eyelid, start with warm compresses 5-10 minutes once or twice daily, gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01%, and gentle massage to express gland contents; if this fails after 1-2 weeks or the lesion is symptomatic, proceed to either intralesional steroid injection or surgical incision and curettage. 1

Initial Clinical Assessment

The most critical first step is distinguishing benign inflammatory lesions from conditions requiring urgent intervention or malignancy:

Red Flags Requiring Immediate Evaluation

• Proptosis, impaired or painful extraocular movements, decreased visual acuity, severe headache, altered mental status, fever, or systemic toxicity indicate orbital cellulitis and require immediate hospitalization, IV antibiotics, contrast-enhanced CT, and urgent ophthalmology consultation 1
• Gradual enlargement, central ulceration or induration, irregular borders, eyelid margin destruction, loss of lashes, or telangiectasia suggest malignancy and require biopsy by an experienced surgeon 1, 2

Common Benign Eyelid Bumps

The differential diagnosis includes:

Hordeolum (Stye) - acute, painful, localized infection of eyelid glands 1, 3

Chalazion - chronic, painless, non-inflammatory retention cyst from blocked meibomian glands 4, 3

Molluscum contagiosum - dome-shaped, umbilicated viral lesions that may cause follicular conjunctivitis 5, 6

Treatment Algorithm by Diagnosis

For Hordeolum (Acute Stye)

First-line conservative management:

• Warm compresses for 5-10 minutes once or twice daily 1
• Gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01% after compresses 1
• Gentle massage to express gland contents 1

Second-line treatment if no improvement in 48-72 hours:

• Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime 1

Important caveat: Despite widespread use of warm compresses and antibiotics, a Cochrane review found no randomized controlled trials supporting these interventions for acute internal hordeolum, though they remain standard practice based on clinical experience 7, 8

For Chalazion (Chronic Retention Cyst)

Conservative management (first 4-6 weeks):

• Warm compresses and lid hygiene 4
• Local antibiotic ointment with or without steroids 4

Definitive treatment for persistent lesions:

• Intralesional triamcinolone acetonide injection 4
• Surgical incision and curettage 4
• Alternative methods include CO2 laser or cryotherapy, though these are less commonly used 4

The choice between injection and surgery depends on lesion size, location, and patient preference, as there is no universally agreed-upon treatment of choice 4

For Molluscum Contagiosum

Definitive treatment requires physical removal of the lesion:

• Incision and curettage (aggressive enough to cause bleeding) 5, 6
• Simple excision 5, 6
• Excision with cautery 5, 6
• Cryotherapy 5, 6

Key management points:

• Carefully examine for and treat nascent lesions simultaneously to reduce recurrence 5, 6
• Associated conjunctivitis may require weeks to resolve after lesion elimination 5, 6
• Multiple or large lesions with minimal conjunctival inflammation should prompt HIV testing 6

Important note: While molluscum lesions can spontaneously resolve, they may persist for 6 months to 5 years, making treatment advisable in symptomatic patients 6

Common Clinical Pitfalls

• Never start steroids before ophthalmology examination if there is any suspicion of infectious keratitis or uveitis, as this may worsen infection or mask accurate diagnosis 1
• Do not assume all eyelid bumps are benign - maintain high suspicion for malignancy in lesions with concerning features, particularly in older patients 2
• Preseptal cellulitis can progress to orbital cellulitis - if eyelid swelling is accompanied by pain, erythema, or any orbital signs, urgent evaluation is mandatory 1
• Contact lens wearers with eyelid bumps may have giant papillary conjunctivitis requiring contact lens abstinence and switching to daily disposables 1

Follow-Up Recommendations

• Hordeolum should improve within 48-72 hours with conservative treatment; lack of improvement warrants escalation 1
• Chalazion may require 4-6 weeks of conservative management before considering definitive intervention 4
• Molluscum contagiosum typically does not require follow-up unless conjunctivitis persists after lesion removal 5, 6
• Any lesion that enlarges, changes character, or fails to respond to appropriate treatment requires biopsy to exclude malignancy 2