What to do for a hordeolum (stye) with a growing visible pustule?

Management of Growing Hordeolum with Visible Pustule

A hordeolum with a growing visible pustule requires incision and drainage as the primary treatment, with antibiotics reserved only for cases with systemic signs of infection or extensive surrounding cellulitis. 1

Immediate Treatment Approach

Perform incision and drainage for any large or enlarging hordeolum with visible pustule. 1 This is the definitive treatment and should not be delayed, as the growing pustule indicates a collection of pus that will not resolve with conservative measures alone. 1

Drainage Technique

• Make an incision to thoroughly evacuate all purulent material 1
• Probe the cavity to break up any loculations or septations 1, 2
• Cover the surgical site with a simple dry sterile dressing 1
• Do not pack the wound with gauze, as this causes more pain without improving healing 1

When to Add Antibiotics

Antibiotics are NOT routinely needed after drainage unless specific criteria are met: 1

Indications for systemic antibiotics (directed against S. aureus):

• Temperature >38°C or <36°C 1
• Tachycardia >90 beats per minute 1
• Tachypnea >24 breaths per minute 1
• White blood cell count >12,000 or <400 cells/µL 1
• Extensive surrounding cellulitis (erythema >5 cm with induration) 1, 2
• Markedly impaired host defenses or immunocompromised state 1

Antibiotic selection if needed:

• Consider MRSA coverage if local prevalence is high or patient has risk factors 1
• Options include penicillinase-resistant penicillins, first-generation cephalosporins, or clindamycin for typical cases 1
• Use MRSA-active agents (vancomycin, doxycycline, clindamycin, or TMP-SMX) if MRSA suspected 1

Conservative Measures (Insufficient for Growing Pustule)

While warm compresses may help small hordeola drain spontaneously, a growing visible pustule indicates this approach has failed and surgical drainage is now required. 1 The evidence shows no controlled trials support conservative management for established acute internal hordeolum. 3, 4

Culture Considerations

Obtain Gram stain and culture of the pus if: 1

• Systemic antibiotics will be used 1
• Multiple lesions are present 1
• Recurrent infections occur 1
• Treatment without culture is reasonable in typical cases where antibiotics are not needed 1

Critical Pitfalls to Avoid

• Do not treat with antibiotics alone without drainage - this will fail as the mechanical problem (pus collection) remains unaddressed 5, 2
• Do not delay drainage hoping for spontaneous resolution - a growing pustule indicates progression requiring intervention 1
• Do not pack the wound unnecessarily - simple dry dressing is superior 1, 2
• Do not prescribe antibiotics routinely - they are unnecessary in most cases after adequate drainage 1

Expected Healing Timeline

Most wounds should heal within 2-3 weeks with simple dressing changes after proper drainage. 2 Persistent drainage beyond this timeframe suggests inadequate initial evacuation requiring repeat drainage. 2

When to Suspect Alternative Diagnosis

If the lesion is recurrent, unilateral, or resistant to standard therapy, consider biopsy to exclude sebaceous carcinoma, especially with focal lash loss or abnormal eyelid margin anatomy. 1