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

Treatment for Styes (Hordeolum)

The first-line treatment for styes is 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

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and promote 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
• Patients should understand this treatment may be required long-term, as symptoms often recur when discontinued 1

Most styes drain spontaneously and resolve with conservative treatment alone 2. However, if there is no improvement after 2-4 weeks, escalation is warranted.

Second-Line Treatment (After 2-4 Weeks Without Improvement)

• Topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins one or more times daily for a few weeks 1
• Mupirocin 2% topical ointment is an alternative option for minor skin infections 1
• The frequency and duration should be guided by severity and response, with consideration of using different antibiotics intermittently to prevent resistant organisms 1

Third-Line Treatment for Persistent or Severe Cases

Oral antibiotics may be considered when symptoms and signs are not adequately controlled by eyelid cleansing or topical treatments:

• Doxycycline, minocycline, or tetracycline for adults (contraindicated in pregnancy and children under 8 years) 1
• Erythromycin or azithromycin as alternatives for women of childbearing age and children 1
• Topical corticosteroids may provide symptomatic relief but should be used with caution and under ophthalmological supervision 1

Surgical Management

• Incision and drainage is recommended for worsening upper eyelid hordeolum that fails conservative management 1
• If signs of spreading infection develop, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection 1
• Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 1

Important Clinical Caveats

• Avoid aggressive eyelid manipulation in patients with advanced glaucoma, as it may increase intraocular pressure 1
• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1
• Monitor intraocular pressure closely if using steroid-containing drops, particularly in patients with advanced glaucoma 1

When to Refer to Ophthalmology

• No improvement after incision and drainage plus appropriate antibiotic therapy 1
• Signs of orbital cellulitis or systemic illness (immediate referral required) 1
• Stye in an area difficult to treat, such as the inner eyelid 1
• Signs of systemic illness or extensive infection 1

Note: A 2013 Cochrane review found no randomized controlled trials evaluating nonsurgical interventions for acute internal hordeolum, highlighting the lack of high-quality evidence for most treatments 2. However, the conservative approach outlined above represents current standard practice based on expert consensus guidelines 1.