What is the recommended treatment for a stye?

Treatment of Stye (Hordeolum)

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing—this conservative approach is the first-line treatment recommended by the American Academy of Ophthalmology for all uncomplicated 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 1, 2
• Ensure the compress is warm but not hot enough to burn the skin 2

Eyelid Cleansing Technique:

• Perform gentle eyelid cleansing once or twice daily, immediately after warm compresses 1, 2, 3
• Gently rub the base of the 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 and are particularly useful 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 1, 2, 3
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during eyelid cleansing 1, 2, 3
• Eyelid cleaning can be dangerous if the patient lacks manual dexterity or necessary skill 2

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

Topical Antibiotic Therapy:

• 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
• Mupirocin 2% topical ointment is an alternative for minor skin infections 1, 3
• 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 1

Third-Line Treatment for Persistent or Severe Cases

Oral Antibiotic Therapy:

• 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 2, 3
• If there are signs of spreading infection, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA infection 3
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 3

Red Flags Requiring Immediate Escalation

When to Refer to Ophthalmology:

• If there is no improvement after incision and drainage plus appropriate antibiotic therapy 2, 3
• If there are signs of orbital cellulitis (proptosis, ophthalmoplegia, vision changes) or systemic illness, immediate referral is necessary 2, 3
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude carcinoma 2

Systemic Treatment Indications:

• 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

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 1, 2, 3
• Regular eyelid hygiene, especially for those prone to styes or with chronic blepharitis, helps prevent recurrence 1, 2

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. 1

• Incision and drainage is not indicated for an already-draining stye; surgical drainage should be reserved for cases that fail conservative management 1
• Avoid aggressive manipulation of the eyelid, particularly in patients with advanced glaucoma 3