What is the treatment for a likely localized infection of the eyelid, possibly hordeolum (stye) or blepharitis, in an adult or adolescent patient with no significant past medical history, presenting with a red, tender eyelid, a bump on the inner outside of the eye, and crusting, but no red eye?

Treatment of Eyelid Infection (Likely Hordeolum or Anterior Blepharitis)

Start with warm compresses applied to the eyelid for several minutes once or twice daily, combined with gentle eyelid hygiene using diluted baby shampoo or commercially available eyelid cleaners, and if symptoms persist after 2-4 weeks, add topical antibiotic ointment (bacitracin or erythromycin) applied to the eyelid margin at bedtime. 1, 2

Initial Conservative Management (First 2-4 Weeks)

Based on your description of a red, tender eyelid with a bump and crusting but no red eye, this presentation is most consistent with either a hordeolum (stye) or anterior blepharitis with possible staphylococcal infection. 3

Begin with these conservative measures:

• Apply warm compresses to the affected eyelid for several minutes once or twice daily using hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags—but avoid temperatures hot enough to burn the skin. 2 This helps soften crusts and promotes drainage. 2

• Perform eyelid hygiene by gently rubbing the base of the eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a cotton ball, cotton swab, or clean fingertip. 2 Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects and are particularly effective. 2

• Maintain this regimen daily as this is typically a chronic condition that requires ongoing management. 2

Escalation to Topical Antibiotics (If No Improvement After 2-4 Weeks)

If eyelid hygiene provides inadequate relief after 2-4 weeks, add topical antibiotics: 2

• Bacitracin or erythromycin ointment applied to the eyelid margins one or more times daily or at bedtime for several weeks. 2 This addresses the likely staphylococcal component, as Staphylococcus aureus is isolated with greater frequency from eyelids of patients with clinical diagnoses of staphylococcal blepharitis. 3

• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 2

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms, as long-term antibiotic use carries this risk. 2

Important Clinical Considerations

Key symptoms that support this diagnosis include: 3, 1

• Redness, irritation, burning, crusting of eyelashes, and recurrent hordeolum
• Morning symptoms are typical of blepharitis (whereas evening symptoms suggest aqueous deficient dry eye) 3, 1

Critical patient education points: 2

• This is typically a chronic condition without a definitive cure—symptoms will recur when treatment is discontinued. 2
• Long-term daily eyelid hygiene is essential for symptom control even after the acute episode resolves. 2
• Many cases of hordeolum drain spontaneously and resolve without treatment. 4, 5

Red Flags Requiring Ophthalmology Referral

Seek ophthalmology consultation if: 1

• Marked asymmetry or unilateral involvement that doesn't respond to therapy (consider carcinoma masquerading as blepharitis) 1
• Vision changes develop
• The condition spreads to involve the eye itself (conjunctiva or cornea)
• Severe inflammation persists despite appropriate treatment

Why This Approach Works

The absence of red eye (no conjunctival involvement) suggests the infection is localized to the eyelid structures rather than spreading to deeper ocular tissues. 3 The combination of warm compresses and eyelid hygiene forms the mainstay of treatment for blepharitis and hordeolum, with topical antibiotics serving as second-line therapy to reduce bacterial load. 1, 2 This stepwise approach balances effectiveness with antibiotic stewardship.