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—this is the first-line treatment recommended by the American Academy of Ophthalmology for most styes. 1, 2

First-Line Conservative Management

Warm Compresses:

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

Eyelid Cleansing:

• Perform gentle eyelid cleansing once or twice daily immediately after warm compresses to help express the contents of the affected gland. 1, 2
• 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
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and are particularly useful. 1, 2
• 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. 1, 2
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing. 1, 2
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or the necessary skill to perform the task safely. 1, 3

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

Topical Antibiotics:

• 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
• Mupirocin 2% topical ointment is an alternative option for minor skin infections. 1, 2
• Topical antibiotics provide symptomatic relief and decrease bacteria from the eyelid margin. 1, 3
• The frequency and duration should be guided by severity and response to treatment. 1, 2

Important Caveat:

• The Infectious Diseases Society of America confirms that simple abscesses and superficial infections should be managed with local measures alone, and oral antibiotics should not be prescribed for simple, uncomplicated styes. 2
• Long-term antibiotic use risks development of resistant organisms, which is particularly concerning since staphylococcal species can cause serious complications like postoperative endophthalmitis. 2, 3

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, 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

Surgical Intervention:

• For worsening hordeolum despite conservative management, incision and drainage is recommended as the next step. 1
• Incision and drainage is not indicated for an already-draining stye; surgical drainage should be reserved for cases that fail conservative management. 2

Red Flags Requiring Immediate Escalation

When to Initiate Systemic Antibiotics:

• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection. 1
• Cellulitis extending >5 cm beyond the stye margins requires systemic antibiotics covering Gram-positive organisms, including MRSA if risk factors present. 2
• Fever >38.5°C, tachycardia >110 bpm, or other systemic signs indicate need for systemic antibiotics. 2
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response. 1

When to Refer to Ophthalmology:

• Signs of orbital cellulitis, such as proptosis, ophthalmoplegia, or vision changes, require immediate ophthalmology referral. 2
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist. 1
• 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

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. 1, 2, 3
• Follow-up should be based on the severity of the condition and response to treatment. 1, 3

Evidence Gap

A 2017 Cochrane systematic review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting the lack of high-quality evidence for treatment recommendations. 4 Despite this, the guideline-based approach outlined above represents current expert consensus from the American Academy of Ophthalmology. 1, 2