Treatment of Stye (Hordeolum)
For uncomplicated styes, start with warm compresses applied 3-4 times daily for 5-10 minutes combined with eyelid hygiene using diluted baby shampoo, and reserve topical antibiotics (bacitracin or erythromycin ointment) for cases that fail to improve after 2-4 weeks of conservative management. 1
Initial Conservative Management (First-Line)
The cornerstone of stye treatment is non-pharmacologic intervention:
- Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and promote spontaneous drainage 1
- Clean the eyelid margin once or twice daily using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
- Perform gentle vertical massage of the eyelid if there is posterior blepharitis or meibomian gland involvement to help express secretions 1
Important caveat: Patients with advanced glaucoma should avoid aggressive eyelid manipulation as it may increase intraocular pressure 1. Patients with neurotrophic corneas require counseling to avoid corneal epithelial injury during cleaning 1.
Topical Antibiotic Therapy (Second-Line)
If no improvement occurs after 2-4 weeks of conservative management:
- Apply topical antibiotic ointment (bacitracin or erythromycin) to the eyelid margins one or more times daily or at bedtime for a few weeks 1, 2
- Mupirocin 2% topical ointment is an alternative option for minor skin infections 1
- Rotate different antibiotics intermittently to prevent development of resistant organisms 1, 2
The frequency and duration should be guided by severity and clinical response 1.
Oral Antibiotics (For Persistent or Severe Cases)
For styes with meibomian gland dysfunction not responding to topical therapy:
- Doxycycline, minocycline, or tetracycline can be prescribed for patients whose symptoms are not adequately controlled by eyelid cleansing or topical treatments 1, 2
- Contraindications: Tetracyclines should not be used in pregnancy, nursing women, or children under 8 years of age due to tooth staining 3
- Alternative for contraindicated patients: Erythromycin or azithromycin for women of childbearing age and children 1, 2
Azithromycin dosing options:
- Oral azithromycin 500 mg daily for 3 days in three cycles with 7-day intervals between cycles 3, 2
- FDA warning: Oral azithromycin may cause cardiac electrical abnormalities with potential for serious heart rhythm irregularities, particularly in patients with high baseline cardiovascular disease risk 3, 2
Surgical Intervention
For worsening styes, incision and drainage is the next step along with warm compresses and consideration of oral antibiotics if there are signs of spreading infection 1. If spreading infection is suspected, particularly with MRSA, consider trimethoprim-sulfamethoxazole or tetracyclines (doxycycline/minocycline), though treatment failure rates up to 21% have been reported with tetracyclines 1.
When to Refer to Ophthalmology
- No improvement after incision and drainage plus appropriate antibiotic therapy 1
- Signs of orbital cellulitis or systemic illness require immediate referral 1
- Stye in difficult-to-treat location such as the inner eyelid 1
Long-Term Management Considerations
Patients should understand that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued 1. This chronic nature of eyelid inflammation means that a "cure" is typically not achievable, and ongoing maintenance therapy may be necessary 2.
Key pitfall: Avoid long-term topical corticosteroids despite their symptomatic benefit, as they increase risk of elevated intraocular pressure and cataract formation 3. If used, limit to 1-2 weeks and use minimal effective doses with site-specific agents like loteprednol etabonate 3, 2.