What is the recommended treatment for a patient presenting with a stye?

Treatment of Stye (Hordeolum)

Begin with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with eyelid cleansing using diluted baby shampoo or commercial eyelid cleaners once or twice daily. 1

First-Line Conservative Management

The initial approach focuses on promoting natural drainage and removing inflammatory debris:

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and facilitate spontaneous drainage 1
• Perform eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
• Gentle vertical massage of the eyelid should be performed for posterior blepharitis or meibomian gland involvement to help express secretions 1
• Continue treatment long-term as symptoms frequently recur when discontinued 1

This conservative approach is sufficient for most cases, as many hordeola drain spontaneously and resolve without additional intervention 2, 3.

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

If the stye persists despite adequate conservative management:

• Topical antibiotic ointment such as bacitracin or erythromycin should be applied to the eyelid margins one or more times daily for several weeks 1
• Mupirocin 2% topical ointment is an alternative option for minor skin infections and secondarily infected lesions 1
• Adjust frequency and duration based on severity and response, with consideration of rotating antibiotics intermittently to prevent resistant organisms 1

Persistent or Severe Cases Requiring Escalation

For styes that worsen or fail to respond to topical therapy:

Oral Antibiotics

• Doxycycline, minocycline, or tetracycline may be considered for meibomian gland dysfunction not adequately controlled by eyelid cleansing or topical treatments 1
• Contraindicated in pregnancy and children under 8 years 1
• Alternative oral antibiotics such as erythromycin or azithromycin should be used for women of childbearing age and children 1
• Reevaluate in 24-48 hours after initiating oral antibiotics to verify clinical response 1

Surgical Intervention

• Incision and drainage is recommended for worsening upper eyelid hordeolum that fails conservative management 1
• Consider oral antibiotics if signs of spreading infection are present, with trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 1

Topical Corticosteroids

• May provide symptomatic relief but should be used with caution and only under ophthalmological supervision 1
• Monitor intraocular pressure closely in patients with advanced glaucoma if steroid-containing drops are used 1

Critical Pitfalls and Caveats

• Avoid aggressive eyelid manipulation in patients with advanced glaucoma, as it may increase intraocular pressure 1
• Counsel patients with neurotrophic corneas to avoid injury to corneal epithelium during eyelid cleaning 1
• Do not use combination steroid-antibiotic preparations as initial therapy; steroids should only be added after 2-3 days of antibiotic-only therapy if needed 4

When to Refer to Ophthalmology

Immediate referral is necessary for:

• Signs of orbital cellulitis or systemic illness 1
• No improvement after incision and drainage plus appropriate antibiotic therapy 1
• Stye in difficult-to-treat locations such as the inner eyelid 1
• Signs of extensive infection requiring more aggressive management 1