Treatment of Sty (Hordeolum)
For uncomplicated external styes, warm compresses applied 3-4 times daily combined with good eyelid hygiene is the primary treatment, with topical antibiotics reserved for cases with significant surrounding cellulitis or failure to improve.
Initial Management Approach
The cornerstone of sty treatment is conservative, supportive care that promotes spontaneous drainage:
- Apply warm compresses to the affected eyelid for 10-15 minutes, 3-4 times daily to promote drainage and resolution 1
- Perform gentle eyelid massage after warm compress application to facilitate drainage of the blocked gland 1
- Maintain eyelid hygiene with regular lid scrubs using diluted baby shampoo or commercial eyelid cleansers 1
- Avoid squeezing or manipulating the lesion, as this can spread infection to surrounding tissues 1
When to Add Antibiotic Therapy
Most uncomplicated styes resolve spontaneously with conservative measures alone. However, antibiotics should be considered in specific circumstances:
Topical Antibiotics
- Use topical antibiotic ointment (erythromycin or bacitracin) applied to the eyelid margin if there is significant surrounding inflammation or cellulitis 2, 1
- Apply 2-3 times daily for 5-7 days 2
Systemic Antibiotics (for complicated cases)
If the infection spreads beyond the immediate eyelid margin with surrounding cellulitis or signs of systemic involvement, treat as a skin and soft tissue infection:
- For suspected MRSA involvement: Use clindamycin 300-450 mg orally three times daily OR trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily for 7-10 days 3, 4
- Verify local clindamycin resistance rates are <10% before prescribing, as inducible resistance is common in MRSA 3
- For non-MRSA cellulitis: Cephalexin or dicloxacillin 500 mg four times daily for 7-10 days 5
Pediatric Considerations
- Topical mupirocin 2% ointment applied three times daily for 5-10 days is recommended for children with minor eyelid infections 5, 4
- Avoid tetracyclines (doxycycline, minocycline) in children <8 years of age due to tooth discoloration risk 5, 3
- For systemic therapy if needed: clindamycin 10-13 mg/kg/dose orally every 6-8 hours (only if local resistance <10%) 5, 6
When to Refer or Escalate Care
- Failure to improve after 48-72 hours of conservative treatment warrants consideration of incision and drainage by ophthalmology 1
- Signs of orbital cellulitis (proptosis, restricted eye movements, vision changes, severe pain) require immediate ophthalmology consultation and IV antibiotics 5
- Recurrent styes should prompt evaluation for underlying blepharitis, seborrheic dermatitis, or diabetes 1
Prevention of Recurrence
For patients with recurrent styes:
- Maintain regular eyelid hygiene with daily lid scrubs using diluted baby shampoo 5
- Practice good hand hygiene with regular handwashing, especially before touching the face 5, 3
- Avoid sharing personal items such as towels, washcloths, or eye makeup 5
- Consider decolonization strategies (intranasal mupirocin twice daily for 5-10 days) if recurrent infections persist despite hygiene measures 5, 6
Critical Pitfalls to Avoid
- Do not routinely prescribe antibiotics for simple, uncomplicated styes without surrounding cellulitis, as most resolve with warm compresses alone 1
- Do not use beta-lactam antibiotics empirically if MRSA is suspected based on local epidemiology or previous cultures, as they are ineffective against methicillin-resistant strains 3
- Do not confuse internal hordeolum with chalazion, which is a chronic granulomatous inflammation requiring different management 7, 8