What is the treatment for a stye (hordeolum)?

Treatment of Stye (Hordeolum)

Warm compresses for 5-10 minutes, 3-4 times daily, combined with gentle eyelid hygiene using diluted baby shampoo or commercial eyelid cleaners, is the first-line treatment for styes, with topical antibiotics (bacitracin or erythromycin) reserved only for cases that fail to improve after 2-4 weeks of conservative management. 1, 2, 3

First-Line Conservative Management

The cornerstone of stye treatment is warm compresses and eyelid hygiene, which should be initiated immediately:

Warm Compress Technique:

• Apply warm compresses to the affected eyelid for 5-10 minutes to soften debris and warm meibomian secretions 1, 2, 3
• Perform 3-4 times daily (or at minimum once or twice daily at convenient times) 2, 3
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in a microwave for sustained warmth 1, 3
• Ensure water is warm but not hot enough to burn the skin 1, 3

Eyelid Hygiene Following Warm Compresses:

• Gently rub 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
• Perform gentle vertical massage of the eyelid to help express the contents of the affected gland 2, 3
• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used 1, 3
• Continue once or twice daily to remove debris and inflammatory material 2, 3

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

Topical Antibiotics:

• Apply bacitracin or erythromycin ointment to the eyelid margins one or more times daily or at bedtime for a few weeks 1, 2, 3
• Mupirocin 2% topical ointment is an alternative option 2
• The frequency and duration should be guided by severity and response to treatment 1, 2, 3
• Topical antibiotics provide symptomatic relief and decrease bacteria from the eyelid margin 1, 3

Severe or Recurrent Cases

Oral Antibiotics:

• Doxycycline, minocycline, or tetracycline may be helpful for patients with meibomian gland dysfunction whose symptoms are not adequately controlled by topical treatments 1, 2
• For women of childbearing age and children under 8 years, use oral erythromycin or azithromycin instead of tetracyclines 1, 2

Surgical Intervention:

• Incision and drainage is recommended for worsening hordeolum that fails conservative management 2
• If there are signs of spreading infection, initiate oral antibiotics along with incision and drainage 2
• Consider trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 2

Critical Safety Considerations and Pitfalls

Patient-Specific Precautions:

• 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 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

Red Flags Requiring Further Evaluation:

• If a stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude carcinoma 1, 3
• If there are signs of orbital cellulitis or systemic illness, immediate referral to an ophthalmologist is necessary 2
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to ophthalmology 2

Antibiotic Resistance Concerns:

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

Long-Term Management and Patient Counseling

• 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, helps prevent recurrence 1
• For recurrent styes, daily eyelid cleansing may help prevent recurrence 1
• Follow-up should be based on the severity of the condition and response to treatment 1, 2, 3

Evidence Quality Note

It is important to note that a Cochrane systematic review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, indicating that current treatment recommendations are based on expert consensus and observational evidence rather than high-quality randomized trials 4, 5. Despite this limitation, the guideline recommendations from the American Academy of Ophthalmology provide a structured, evidence-informed approach to management 1, 2, 3.