What is the recommended treatment for a stye (hordeolum)?

Stye (Hordeolum) Treatment

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing and massage—this is the first-line treatment recommended by the American Academy of Ophthalmology, with topical antibiotics reserved only for cases that fail to improve after 2-4 weeks of conservative management. 1, 2

First-Line Conservative Management (Start Here for All Cases)

Warm Compresses

• Apply warm compresses to the affected eyelid 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, 3

Eyelid Cleansing and Massage

• 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, 3
• Apply gentle vertical massage of the eyelid to help express secretions from the meibomian glands 1

Critical Safety Warnings

• 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, 3

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

• 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, 3
• 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 1

Important caveat: Despite widespread use of topical antibiotics, a 2017 Cochrane review found no randomized controlled trials demonstrating their effectiveness for acute internal hordeolum, highlighting that this recommendation is based on expert consensus rather than high-quality evidence 4

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) 1, 3
• Tetracyclines are contraindicated in pregnancy and children under 8 years 1, 3
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 1, 3

Surgical Intervention

• For worsening hordeolum despite conservative management, incision and drainage is recommended as the next step 1
• If there are signs of spreading infection, 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 Referral

• 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 1
• If there are signs of orbital cellulitis or systemic illness, immediate referral to an ophthalmologist is necessary 1

Long-Term Management and Prevention

• 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 3
• A schedule of regularly performed eyelid cleansing, daily or several times weekly, often reduces symptoms of chronic blepharitis 3
• Follow-up should be based on the severity of the condition and response to treatment 1, 2, 3