What is the recommended treatment for a stye?

Stye Treatment

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing—this conservative approach is first-line therapy and resolves most styes without antibiotics. 1, 2, 3

First-Line Conservative Management (All Cases)

Warm Compresses:

• Apply 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, 3
• Ensure water is warm but not hot enough to burn the skin 1
• This softens debris, warms meibomian secretions, and promotes spontaneous drainage 1, 2

Eyelid Cleansing:

• Perform once or twice daily immediately after warm compresses 1, 2, 3
• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1, 2, 3
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects 1, 2
• Apply gentle vertical massage to help express secretions from meibomian glands 1, 2, 3

Critical Safety Warnings:

• Patients with advanced glaucoma must avoid aggressive eyelid pressure as it may increase intraocular pressure 1, 2, 3
• Patients with neurotrophic corneas require counseling to avoid corneal epithelial injury during cleansing 1, 2, 3
• Assess patient's manual dexterity before recommending self-treatment 4

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

Topical Antibiotics:

• Prescribe bacitracin or erythromycin ointment applied to eyelid margins 1-3 times daily for a few weeks 1, 2, 3
• Mupirocin 2% ointment is an alternative for minor skin infections 1, 3
• Important caveat: Long-term antibiotic use risks development of resistant organisms, particularly concerning since staphylococcal species can cause serious complications like postoperative endophthalmitis 4, 2

Third-Line Treatment (Persistent or Severe Cases)

Oral Antibiotics:

• Consider doxycycline, minocycline, or tetracycline for cases not controlled by topical treatments 1, 2, 3
• Contraindicated in pregnancy and children under 8 years 1, 2, 3
• For women of childbearing age and children, use oral erythromycin or azithromycin instead 1, 2, 3

Surgical Intervention:

• Incision and drainage is recommended for worsening hordeolum despite conservative management 1, 3
• Do not perform incision and drainage on an already-draining stye—surgical drainage is reserved for cases failing conservative management 2

Red Flags Requiring Immediate Escalation

When to Initiate Systemic Antibiotics:

• Cellulitis extending >5 cm beyond stye margins 2
• Fever >38.5°C or tachycardia >110 bpm 2
• Signs of spreading infection—consider trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA 1, 3
• Reevaluate patients on oral antibiotics in 24-48 hours to verify clinical response 1, 3

When to Refer to Ophthalmology:

• Signs of orbital cellulitis (proptosis, ophthalmoplegia, vision changes) require immediate referral 1, 2, 3
• No improvement after incision and drainage plus appropriate antibiotics 1, 3
• Markedly asymmetric, therapy-resistant, or recurrent styes in the same location—consider biopsy to exclude carcinoma 1

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, 2

Advise patients that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued 4, 1, 2, 3

Note: A Cochrane review found no randomized controlled trials supporting any specific nonsurgical intervention for acute internal hordeolum, highlighting that current recommendations are based on expert consensus and observational data 5