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

Treatment for a Draining Stye (Hordeolum)

For a draining stye, continue warm compresses and eyelid hygiene as the primary treatment, and add topical antibiotic ointment (bacitracin or erythromycin) to the eyelid margins 1-3 times daily if significant inflammation persists or drainage is copious. 1

Primary Conservative Management

The fact that the stye is already draining is favorable—most styes drain spontaneously and resolve without aggressive intervention. 1 Your treatment approach should focus on:

Warm Compress Regimen

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily using hot tap water on a clean washcloth, over-the-counter heat pack, or microwaveable bean/rice bag. 1, 2
• Ensure compresses are not hot enough to burn the skin. 1
• This softens adherent material, warms meibomian secretions, and promotes continued drainage. 1, 2

Eyelid Hygiene

• After each warm compress application, perform gentle eyelid cleansing using diluted baby shampoo or commercially available eyelid cleaner on a cotton swab or clean fingertip. 1, 2
• Gently rub the base of the eyelashes to remove crusting and drainage material. 1
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and are particularly useful. 1
• Continue this regimen once or twice daily until complete resolution. 1

When to Add Topical Antibiotics

Since the stye is actively draining, topical antibiotics are reasonable to add now, particularly if there is significant surrounding inflammation or copious purulent drainage. 1

• Apply bacitracin ointment or erythromycin ointment to the eyelid margins 1-3 times daily. 1, 3
• The FDA-approved dosing for bacitracin is to apply a small amount (equal to the surface area of a fingertip) to the affected area 1-3 times daily. 3
• Continue for a few weeks, then reassess. 1

What NOT to Do

Avoid Systemic Antibiotics

Do not prescribe oral antibiotics for a simple draining stye. 1 Styes are superficial infections that typically resolve with local measures alone. 1 The IDSA guidelines confirm that simple abscesses and superficial infections should be managed with incision and drainage (or spontaneous drainage) without antibiotics. 4

Avoid Surgical Intervention

Incision and drainage is not indicated for an already-draining stye. 1 Surgical drainage should be reserved for cases that fail conservative management or develop into abscesses that do not drain spontaneously. 1

Red Flags Requiring Escalation

Watch for signs that would require systemic antibiotics or urgent referral:

• Cellulitis extending >5 cm beyond the stye margins suggests more severe infection requiring systemic antibiotics. 5
• Fever >38.5°C, tachycardia >110 bpm, or other systemic signs indicate the need for systemic antibiotics covering Gram-positive organisms (including MRSA if risk factors present). 5
• Signs of orbital cellulitis (proptosis, ophthalmoplegia, vision changes) require immediate ophthalmology referral. 2
• Marked asymmetry or resistance to therapy may indicate sebaceous carcinoma and warrants eyelid biopsy. 2

Common Pitfalls to Avoid

• Long-term antibiotic use risks resistant organisms, which is particularly concerning since staphylococcal species can cause serious complications like postoperative endophthalmitis. 2
• Recurrence is common when treatment is discontinued prematurely—counsel patients that symptoms often recur and treatment may need to be long-term or intermittent. 1, 2
• Patients lacking manual dexterity should receive modified instructions to avoid injury during eyelid cleaning. 1

Evidence Quality Note

The Cochrane reviews from 2013 and 2017 found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting that current recommendations are based on expert consensus rather than high-quality evidence. 6, 7 However, the American Academy of Ophthalmology guidelines provide clear, practical recommendations that align with standard clinical practice. 1, 2