What is the treatment for a stye (hordeolum)?

Treatment for Stye (Hordeolum)

Start with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing—this is the first-line treatment recommended by the American Academy of Ophthalmology and is effective for most cases. 1, 2

First-Line Conservative Management

The cornerstone of stye treatment is consistent local therapy that promotes spontaneous drainage:

• Apply warm compresses for 5-10 minutes, 3-4 times daily using hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1, 2
• The water should be warm enough to soften debris and meibomian secretions but not hot enough to burn the skin 3, 1
• Perform gentle eyelid cleansing once or twice daily immediately after warm compresses using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 2
• Gently rub the base of the eyelashes to remove crusting and inflammatory material 3, 2
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and are particularly useful 3, 1
• Apply gentle vertical massage of the eyelid to help express secretions from the meibomian glands 1, 2

Critical Safety Warnings

• Patients with advanced glaucoma should avoid aggressive eyelid pressure as it may increase intraocular pressure 3, 1
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing 3, 1
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or necessary skill 3, 1

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

If conservative measures fail after 2-4 weeks of consistent application:

• Prescribe topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins 1-3 times daily for a few weeks 1, 2
• Mupirocin 2% topical ointment is an alternative for minor skin infections 1, 2
• The frequency and duration should be guided by severity and response to treatment 1, 2
• Long-term antibiotic use risks development of resistant organisms, which is particularly concerning since staphylococcal species can cause serious complications like postoperative endophthalmitis 3, 4

Third-Line Treatment for Severe or Recurrent Cases

For moderate to severe cases with meibomian gland dysfunction not adequately controlled:

• Consider oral tetracyclines (doxycycline, minocycline, or tetracycline) for patients whose symptoms are not controlled by topical treatments 1, 2
• Tetracyclines are contraindicated in pregnancy and children under 8 years 1, 2
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 1, 2

When Surgical Intervention Is Needed

• For worsening hordeolum despite conservative management, incision and drainage is recommended as the next step 1, 2
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection 1, 2
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 1, 2

Red Flags Requiring Escalation

Watch for these signs that indicate more aggressive treatment or referral:

• Cellulitis extending >5 cm beyond the stye margins requires systemic antibiotics covering Gram-positive organisms (including MRSA if risk factors present) 3, 4
• Fever >38.5°C, tachycardia >110 bpm, or other systemic signs indicate need for systemic antibiotics 3, 4
• Signs of orbital cellulitis (proptosis, ophthalmoplegia, vision changes) require immediate ophthalmology referral 1, 2
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude carcinoma 1
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist 1, 2

Long-Term Management Expectations

• 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, 4, 2
• Regular eyelid hygiene, especially for those prone to styes or with chronic blepharitis, helps prevent recurrence 1, 2
• Most styes drain spontaneously and resolve without aggressive intervention when treated with consistent conservative measures 4

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics for simple, uncomplicated styes—the Infectious Diseases Society of America confirms that simple abscesses and superficial infections should be managed with local measures alone 4
• Incision and drainage is not indicated for an already-draining stye; surgical drainage should be reserved for cases that fail conservative management 4
• Avoid premature discontinuation of treatment, as recurrence is common 4, 2

Evidence Quality Note

A Cochrane systematic review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting that current recommendations are based on expert consensus and observational data rather than high-quality trial evidence 5, 6