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

Treatment of Stye (Hordeolum)

First-line treatment for a stye consists of warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing and massage to promote drainage. 1, 2

First-Line Conservative Management

Warm Compresses

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften debris, warm meibomian secretions, and promote spontaneous 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 Cleansing and Massage

• After warm compresses, gently clean the eyelid margin using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 2
• Perform gentle vertical massage of the eyelid to help express the contents of the affected gland 1, 2
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and can be used 1, 3
• Continue this regimen once or twice daily at convenient times 1, 2

Second-Line Treatment (If No Improvement After 2-4 Weeks)

If conservative measures fail after 2-4 weeks, add topical antibiotic ointment to the regimen. 2

• 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

Management of Severe or Worsening Cases

Incision and Drainage

• For worsening hordeolum despite conservative treatment, incision and drainage is the next step in management 2
• Continue warm compresses alongside this intervention 2

Oral Antibiotics

• If there are signs of spreading infection, initiate oral antibiotics 2
• Consider 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
• Reevaluate patients on oral antibiotics in 24-48 hours to verify clinical response 2

Important Cautions and Special Considerations

Safety Precautions

• Patients with neurotrophic corneas require 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, 3
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or skill to perform the task safely 3
• Long-term antibiotic treatment may result in development of resistant organisms 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 the possibility of 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

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
• Follow-up should be based on the severity of the condition and response to treatment 1, 3

Evidence Quality Note

A 2017 Cochrane review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, indicating that current treatment recommendations are based on clinical experience and expert consensus rather than high-quality evidence 4. Despite this limitation, the American Academy of Ophthalmology guidelines provide a clear, stepwise approach that prioritizes conservative management before escalating to more invasive interventions 1, 2, 3.