What is the treatment for an eye stye (hordeolum)?

Treatment for Eye Stye (Hordeolum)

Warm compresses applied for 5-10 minutes once or twice daily, followed by gentle eyelid cleansing, is the first-line treatment for eye styes, with topical antibiotic ointments (bacitracin or erythromycin) reserved for cases that don't respond to conservative management within 2-4 weeks. 1, 2, 3

First-Line Conservative Treatment

Start with warm compresses and eyelid hygiene for all styes:

• Apply warm compresses to the affected eyelid for 5-10 minutes to soften debris and warm the meibomian secretions 1, 2, 3
• Perform this once or twice daily at times convenient for the patient 1, 3
• Use water that is warm but not hot enough to burn the skin 1, 2, 3
• 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, 3

After warm compresses, perform gentle eyelid cleansing:

• 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, 3
• Apply gentle vertical massage of the eyelid to help express secretions from the affected gland 1, 2

Critical Safety Warnings

Before recommending eyelid cleansing, assess the patient's ability to perform this safely:

• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or the necessary skill to perform the task safely 1, 2, 3
• 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

Second-Line Treatment: Topical Antibiotics

If no improvement after 2-4 weeks of conservative management, prescribe topical antibiotic ointment:

• Bacitracin ophthalmic ointment: Apply directly to the eyelid margins 1 to 3 times daily 4
• Erythromycin ophthalmic ointment: Apply approximately 1 cm in length directly to the affected eye up to 6 times daily, depending on severity 5
• Apply 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, 2
• Caution: Long-term antibiotic treatment may result in the development of resistant organisms 1, 3

Third-Line Treatment for Severe or Recurrent Cases

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 2
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 2, 3

For worsening hordeolum despite conservative management:

• Incision and drainage is recommended as the next step 2
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection 2
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 2

When to Consider Biopsy or Referral

Red flags requiring further evaluation:

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

Long-Term Management and Prevention

Set realistic expectations with patients:

• 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
• A schedule of regularly performed eyelid cleansing, daily or several times weekly, often reduces symptoms and prevents recurrence 3
• For recurrent styes, daily eyelid cleansing may help prevent recurrence 3

Evidence Quality Note

The American Academy of Ophthalmology guidelines provide the framework for this treatment approach 6, 1, 2, 3. However, a Cochrane review found no high-quality randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting that current recommendations are based on clinical experience rather than robust trial evidence 7, 8. Despite this limitation, the conservative approach of warm compresses and eyelid hygiene remains the standard of care given its safety profile and clinical effectiveness in practice.