What is the treatment for hordeolum?

Treatment of Hordeolum

First-Line Conservative Management

Warm compresses applied to the affected eyelid for 5-10 minutes, several times daily (3-4 times), combined with eyelid hygiene measures, represent the cornerstone of initial hordeolum treatment. 1, 2

• Apply warm compresses for 5-10 minutes, 3-4 times daily to increase blood circulation, promote spontaneous drainage of purulent material, and relieve pain 1, 2
• After warm compresses, perform gentle massage of the affected area to help express the obstructed gland 1
• Clean eyelid margins with mild soap or commercial eyelid cleansers as part of regular eyelid hygiene 1
• Discontinue eye makeup use during active infection 1
• Most cases resolve spontaneously within 5-14 days with conservative management alone 2

Critical warning: Never squeeze or attempt to "pop" the hordeolum, as this may spread infection to adjacent tissues. 1

Topical Antibiotic Therapy

Topical antibiotic drops or ointment should be prescribed for moderate to severe cases or when signs of spreading infection are present. 1, 2

• Topical antibiotics protect against secondary bacterial infection and treat the primary staphylococcal infection 2
• Antibiotic choice should account for normal eyelid and conjunctival flora 2
• Erythromycin ophthalmic ointment is FDA-approved for superficial ocular infections involving the conjunctiva and/or cornea caused by susceptible organisms 3

Oral Antibiotic Therapy

Oral antibiotics are reserved for severe cases with spreading infection or systemic symptoms. 1

• Consider oral antibiotics when there is evidence of preseptal cellulitis or systemic involvement 1
• Early aggressive treatment is critical when infection spreads beyond the localized hordeolum to prevent devastating complications including eyelid necrosis 4

Management of Recurrent Hordeola

For patients with recurrent hordeola, implement a more aggressive eyelid hygiene regimen and evaluate for underlying predisposing conditions. 1, 2

• Assess for chronic blepharitis or meibomian gland dysfunction, which commonly predispose to recurrent hordeola 1, 2
• Treat underlying conditions such as rosacea or seborrheic dermatitis 2
• Institute regular preventive eyelid hygiene measures 2
• Consider addressing moderate to severe blepharitis prior to intraocular surgical procedures to reduce complication risk 1

When to Modify Treatment

If no improvement occurs after 48 hours of appropriate therapy, modify the treatment approach. 1

• Reassess the diagnosis to ensure it is not a chalazion (chronic, non-infectious inflammation with gradual onset) rather than acute hordeolum 1, 5
• Consider escalation to topical or oral antibiotics if not already prescribed 1

Red Flags Requiring Further Evaluation

Marked asymmetry, resistance to therapy, or unifocal recurrent lesions—especially in elderly patients—should raise suspicion for sebaceous carcinoma and prompt biopsy consideration. 1, 5, 2

• Eyelid margin distortion, lash loss (madarosis), or ulceration warrant ophthalmology referral 5
• Unilateral chronic blepharitis unresponsive to therapy requires further workup 5, 2
• Recurrence in the same location, particularly in elderly patients, necessitates evaluation for possible sebaceous carcinoma 1, 5, 2

Evidence Quality Note

The evidence base for hordeolum treatment is notably weak, with current recommendations based primarily on expert consensus from the American Academy of Ophthalmology rather than randomized controlled trials 2. Two Cochrane reviews found no randomized trials meeting inclusion criteria for acute internal hordeolum treatment 6, 7. One Cochrane review on acupuncture for hordeolum included only low to very low-certainty evidence from Chinese populations 8.