What is the recommended management for a stye in a pediatric patient?

Management of Stye (Hordeolum) in Children

Begin with warm compresses applied to the affected eyelid for 10-15 minutes, 3-4 times daily, combined with gentle eyelid hygiene using diluted baby shampoo, and add topical antibiotic ointment (erythromycin 0.5%) if no improvement occurs after 48-72 hours or if signs of spreading infection develop. 1

Initial Conservative Treatment (First-Line)

• Apply warm compresses to the affected eyelid for 10-15 minutes, 3-4 times daily to promote spontaneous drainage 1
• Clean the eyelid margin gently with diluted baby shampoo or commercially available eyelid scrubs to maintain good eyelid hygiene 1
• Instruct the child to avoid squeezing or manipulating the lesion, as this spreads infection to surrounding tissues 1
• Continue this conservative approach for 48-72 hours before escalating therapy 1

When to Add Topical Antibiotics

Add topical antibiotics if the stye has not improved after 48-72 hours of warm compresses OR if signs of spreading cellulitis appear. 1

• Apply erythromycin 0.5% ophthalmic ointment to the eyelid margin 2-3 times daily for 5-7 days 1
• Bacitracin ointment is an alternative option for children 2 years and older, applied 1-3 times daily to the affected area 2
• Recent evidence supports shorter antibiotic courses (5 days) as equally effective as longer courses (7-10 days) for uncomplicated cases 1

When to Prescribe Oral Antibiotics

Oral antibiotics are indicated when preseptal cellulitis develops, multiple hordeola are present with systemic infection signs, or the child has fever or appears systemically ill. 1

• First-line oral agent: Cephalexin 25-50 mg/kg/day divided into 3-4 doses for 5-7 days, providing coverage for methicillin-sensitive Staphylococcus aureus 1
• If MRSA is suspected: Clindamycin 10-13 mg/kg/dose three times daily (maximum 40 mg/kg/day) for 5-7 days, but only if local clindamycin resistance rates are <10% 1

Red Flags Requiring Urgent Ophthalmology Referral

• Recurrent hordeola occurring in the same location 1
• Vision changes or eye pain 1
• Proptosis or restricted eye movements 1
• Underlying chronic blepharokeratoconjunctivitis 1

Critical Pitfall: Don't Dismiss Recurrent Styes as Benign

Children with recurrent styes have an increased risk of developing adult rosacea and may represent early ocular rosacea before facial manifestations appear. 3

• Recurrent styes warrant evaluation for underlying blepharitis, meibomian gland dysfunction, or ocular rosacea 3, 1
• Without treatment, severe staphylococcal blepharitis may lead to eyelash loss, eyelid scarring with trichiasis, and corneal scarring 3
• The incidence of ulceration and perforation complications is greater in children compared to adults with blepharitis 3
• Examine for eyelid margin findings: telangiectasia, meibomian gland orifice narrowing/pouting, cylindrical dandruff at eyelash base, and blood-tinged debris 3
• Asymmetry of ocular involvement suggests ocular rosacea in children 3

Prevention Strategies for Recurrent Cases

• Implement daily eyelid hygiene with warm compresses and gentle lid scrubs 1
• Treat underlying blepharitis or seborrheic dermatitis 1
• Ensure the child avoids touching or rubbing the eyes and maintains good hand hygiene 1

Special Considerations

• In children with pediculosis palpebrarum (pubic lice) causing blepharitis, consider sexual abuse and perform appropriate evaluation 3
• Children on isotretinoin for severe acne have increased S. aureus colonization and blepharitis risk 3
• Children on dupilumab for atopic dermatitis experience conjunctivitis, keratitis, and blepharitis in 32-55% of cases 3