What is the treatment for an internal hordeolum (stye) on the upper eyelid?

Treatment of Internal Stye (Hordeolum Internum) of the Upper Eyelid

Begin with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing and massage—this conservative approach is the first-line treatment recommended by the American Academy of Ophthalmology and should be continued for 2-4 weeks before escalating therapy. 1

First-Line Conservative Management (Weeks 1-4)

Warm Compress Application

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

Eyelid Cleansing and Massage

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

Important Safety Considerations

• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing 2, 1
• Patients with advanced glaucoma (with or without filtering procedures) should avoid aggressive eyelid pressure as it may increase intraocular pressure 2, 1
• Patients lacking manual dexterity or necessary skill should receive modified instructions or assistance 2, 1

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

Topical Antibiotic Therapy

• 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 2, 1, 3
• Topical antibiotics provide symptomatic relief and decrease bacteria from the eyelid margin 2, 1
• Mupirocin 2% topical ointment is an alternative option 1
• The frequency and duration should be guided by severity and response to treatment 2, 1
• Use topical antibiotics intermittently with different medications to prevent development of resistant organisms 2, 3

Third-Line Treatment for Severe or Recurrent Cases

Oral Antibiotic Therapy

• For moderate to severe cases with meibomian gland dysfunction not adequately controlled by topical treatments, prescribe oral tetracyclines (doxycycline, minocycline, or tetracycline) given daily and tapered after clinical improvement 2, 1, 3
• Tetracyclines are absolutely contraindicated in pregnancy, nursing women, and children under 8 years of age due to tooth staining 2, 1
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 2, 1
• Pediatric erythromycin dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 2
• Pediatric azithromycin dosing: 5 mg/kg daily for 2 months 2

Surgical Intervention

• For worsening hordeolum despite conservative management, incision and drainage is the next recommended step 1
• If signs of spreading infection develop, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection 1
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 1

When to Consider Biopsy or Specialist Referral

Red Flags Requiring Further Investigation

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

Long-Term Management and Prevention

• Patients should understand that warm compress and eyelid cleansing treatment may be required long-term, as symptoms often recur when treatment is discontinued 2, 1, 3
• Regular eyelid hygiene is essential for those prone to styes or with chronic blepharitis to prevent recurrence 1, 3
• Follow-up should be based on the severity of the condition and response to treatment 1

Evidence Quality Note

The Cochrane Collaboration found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, indicating that current treatment recommendations are based on expert consensus and observational data rather than high-quality trial evidence 4, 5. Despite this limitation, the American Academy of Ophthalmology guidelines provide a structured, evidence-based approach that prioritizes patient safety and stepwise escalation of therapy.