What is the recommended treatment for a stye?

Stye Treatment

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 for most styes. 1, 2, 3

First-Line Conservative Management

Warm Compress Application:

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften debris, warm meibomian secretions, and promote spontaneous drainage. 1, 2, 3
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags—but ensure the temperature is warm enough to be therapeutic without burning the skin. 4, 1
• Sustained warmth is critical for effectiveness. 4

Eyelid Cleansing:

• Perform gentle eyelid cleansing once or twice daily, immediately after warm compresses. 1, 2, 3
• Use diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip to gently rub the base of the eyelashes. 4, 1, 2
• Eye cleaners containing hypochlorous acid at 0.01% have strong antimicrobial effects and are particularly useful. 4, 1, 2
• Apply gentle vertical massage of the eyelid to help express secretions from the meibomian glands. 1, 2, 3

Critical Safety Warnings:

• Patients with advanced glaucoma must avoid aggressive eyelid pressure, as it may increase intraocular pressure. 4, 1, 2, 3
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing. 4, 1, 2, 3
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or necessary skill to perform the task safely. 4, 2

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 1-3 times daily for a few weeks. 1, 2, 3
• Bacitracin should be applied in a small amount (equal to the surface area of the tip of a finger) on the affected area 1 to 3 times daily and may be covered with a sterile bandage. 5
• Mupirocin 2% topical ointment is an alternative for minor skin infections. 1, 3
• Topical antibiotics provide symptomatic relief and decrease bacteria from the eyelid margin. 4, 2

Important Caveat:

• Long-term antibiotic use risks development of resistant organisms, which is particularly concerning since staphylococcal species can cause serious complications like postoperative endophthalmitis. 4, 1
• Consider using different antibiotics intermittently to prevent development of resistant organisms. 3

Third-Line Treatment for Severe or Recurrent Cases

Oral Antibiotics:

• Consider oral tetracyclines (doxycycline, minocycline, or tetracycline) for patients whose symptoms are not controlled by topical treatments. 1, 2, 3
• Tetracyclines are 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:

• For worsening hordeolum despite conservative management, incision and drainage is recommended as the next step. 2, 3
• Incision and drainage is not indicated for an already-draining stye. 1

Red Flags Requiring Immediate Escalation

When to Initiate Systemic Antibiotics:

• Cellulitis extending >5 cm beyond the stye margins requires systemic antibiotics covering Gram-positive organisms, including MRSA if risk factors present. 1
• Fever >38.5°C, tachycardia >110 bpm, or other systemic signs indicate need for systemic antibiotics. 1
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection. 2, 3
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response. 2, 3

When to Refer to Ophthalmology:

• Signs of orbital cellulitis, such as proptosis, ophthalmoplegia, or vision changes, require immediate ophthalmology referral. 1, 2, 3
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist. 2, 3
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma. 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. 4, 1, 2, 3
• Regular eyelid hygiene, especially for those prone to styes or with chronic blepharitis, helps prevent recurrence. 1, 2
• Once- or twice-daily compresses and massage, at a time most convenient for the patient, is generally adequate. 4

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics for simple, uncomplicated styes—simple abscesses and superficial infections should be managed with local measures alone. 1
• Avoid aggressive manipulation of the eyelid, as frequent manipulation may lead to mechanically induced irritation. 4
• Topical corticosteroids may provide symptomatic relief but should be used with caution and under ophthalmological supervision, particularly in patients with advanced glaucoma where intraocular pressure must be monitored closely. 3