What is the treatment for an internal stye (hordeolum internus)?

Treatment for Internal Stye (Hordeolum Internus)

Start with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, followed by gentle eyelid cleansing and massage—this is the first-line treatment recommended by the American Academy of Ophthalmology. 1, 2, 3

First-Line Conservative Management

Warm Compress Technique

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften debris, warm meibomian secretions, and promote spontaneous drainage 1, 2, 3
• Use water that is warm but not hot enough to burn the skin 1, 2
• For sustained warmth, use hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in the microwave 1, 2

Eyelid Hygiene After Warm Compresses

• Perform gentle eyelid cleansing once or twice daily immediately after warm compresses to help express the contents of the affected gland 1, 2, 3
• 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
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and can be used 1, 2
• Apply gentle vertical massage of the eyelid to help express secretions from the meibomian glands 3

Important Safety Considerations

• Patients with neurotrophic corneas need proper counseling to avoid injury to the corneal epithelium during eyelid cleansing 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 the necessary skill to perform the task safely 1, 2

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

Topical Antibiotics

• Prescribe topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins one 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 3

Caution with Antibiotics

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

Third-Line Treatment for Severe or Recurrent Cases

Oral Antibiotics

• For moderate to severe cases with meibomian gland dysfunction not adequately controlled by topical treatments, consider oral tetracyclines (doxycycline, minocycline, or tetracycline) 2, 3
• Tetracyclines are contraindicated in pregnancy and children under 8 years 3
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 2, 3

Surgical Intervention

• For worsening hordeolum despite conservative management, incision and drainage is recommended as the next step 3
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection 3
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 3

When to Consider Biopsy or Referral

Red Flags Requiring Further Investigation

• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 4, 1, 2, 3
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist 3
• If there are signs of orbital cellulitis or systemic illness, immediate referral to an ophthalmologist is necessary 3

Long-Term Management Expectations

• 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 2
• Follow-up should be based on the severity of the condition and response to treatment 1, 2

Evidence Quality Note

While the American Academy of Ophthalmology provides clear treatment guidelines 1, 2, 3, Cochrane systematic reviews found no high-quality randomized controlled trials specifically evaluating non-surgical interventions for acute internal hordeolum 5, 6. Despite this lack of trial evidence, the guideline recommendations represent expert consensus based on clinical experience and pathophysiologic rationale.