What is the difference between a hordeolum (stye) and a chalazion, and how are they treated?

Hordeolum vs. Chalazion: Key Differences and Management

Distinguishing Features

A hordeolum is an acute, painful, erythematous nodule at the eyelid margin with rapid onset and purulent discharge, while a chalazion is a painless, chronic nodule within the tarsal plate with gradual onset and visible meibomian gland obstruction. 1, 2

Hordeolum (Stye)

• Acute inflammatory process with rapid onset (hours to days) 1, 3
• Painful and tender with localized erythema and swelling 1, 3
• Located at the eyelid margin 1, 2
• May have purulent discharge 1, 3
• Frequently associated with bacterial blepharitis (Staphylococcus aureus) 1, 3
• Represents an acute infection of eyelid glands 4

Chalazion

• Painless nodule with gradual onset (weeks) 1, 2
• Located within the tarsal plate (deeper in eyelid) 1, 2
• Visible meibomian gland obstruction on eyelid eversion 1, 2
• Associated with meibomian gland dysfunction or posterior blepharitis 1, 2
• Represents chronic lipogranulomatous inflammation from sebaceous gland obstruction 4
• Can persist for months but may resolve spontaneously 1

Treatment Approach

Hordeolum Management

First-line treatment combines warm compresses (10-15 minutes, 3-4 times daily) with topical antibiotic drops or ointment, as most cases resolve spontaneously within 5-14 days. 1

• Apply warm compresses for 10-15 minutes, 3-4 times daily to promote spontaneous drainage 1
• Gentle massage of the affected area after warm compresses helps express the obstructed gland 2
• Prescribe topical antibiotics (drops or ointment) to treat staphylococcal infection and prevent secondary bacterial spread 1
• Institute regular eyelid hygiene measures, cleaning margins with mild soap or commercial eyelid cleansers 2
• Most practitioners pursue conservative management for 5-14 days before considering incision and curettage 5

Important caveat: The evidence base for hordeolum treatment is notably weak, with recommendations based primarily on expert consensus rather than controlled trials 1, 6, 7

Chalazion Management

Conservative management with warm compresses and eyelid hygiene is first-line, but persistent lesions beyond 4-6 weeks require surgical intervention or intralesional steroid injection. 1, 2

• Warm compresses for 5-10 minutes, several times daily 2
• Eyelid hygiene with mild soap or commercial cleansers 2
• Treat underlying blepharitis or meibomian gland dysfunction before addressing the chalazion 2
• For persistent lesions: intralesional steroid injection (diluted triamcinolone acetonide preferred) or surgical incision and curettage 2, 5
• Intense pulsed light with meibomian gland expression shows promise for recurrent multiple chalazia 2
• Topical antibiotics are used less frequently than for hordeolum (only 26.3% of practitioners always recommend them) 5

Critical Red Flags Requiring Biopsy

Any chalazion with marked asymmetry, resistance to therapy, recurrence in the same location (especially in elderly patients), or atypical features mandates biopsy to exclude sebaceous carcinoma. 2

• Recurrence in the same location, particularly in elderly patients 1, 2, 3
• Marked asymmetry or resistance to standard therapy 2, 3
• Unifocal recurrent lesions unresponsive to therapy 2, 3
• Atypical features: eyelid margin distortion, focal lash loss (madarosis), or ulceration 2, 3
• Unilateral chronic blepharitis unresponsive to therapy 1, 2, 3
• History of multiple excisions at the same site 1
• Avoid prolonged conservative management beyond 4-6 weeks without reassessment, as this delays diagnosis of potential malignancy 2

Prevention Strategies

• Regular eyelid hygiene for patients with blepharitis or meibomian gland dysfunction 1, 2
• Treatment of underlying conditions: rosacea, seborrheic dermatitis 1, 2
• Avoid eye makeup during active inflammation 1, 2
• More aggressive eyelid hygiene regimen for recurrent hordeola 2

Special Populations

Pediatric Considerations

• Children with chalazia should be evaluated for chronic blepharokeratoconjunctivitis, which may present with recurrent conjunctivitis and keratitis 1, 2
• Practitioners extend conservative management longer and delay surgical interventions in pediatric cases (81.4% of practitioners) 5
• Anesthesia preferences vary: 50% favor local anesthesia, 23.8% monitored anesthesia care, 16.2% general anesthesia 5

Common Pitfalls to Avoid

• Failure to distinguish between acute hordeolum (infection) and chronic chalazion (non-infectious inflammation) 3
• Missing underlying chronic blepharitis that predisposes to recurrent lesions 3
• Overlooking sebaceous carcinoma in recurrent unilateral disease resistant to therapy 3
• Prolonged conservative management without reassessment in atypical cases 2