What is the best treatment for an adult patient with a stye?

Treatment of Stye (Hordeolum) in Adults

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

First-Line Conservative Management

The cornerstone of stye treatment is conservative therapy, which resolves most cases without need for antibiotics or surgical intervention:

• Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and promote spontaneous drainage 1
• Clean the eyelid margin once or twice daily using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
• Perform gentle vertical massage of the eyelid if there is meibomian gland involvement to help express secretions 1

This conservative approach should be continued for 2-4 weeks before escalating treatment. 1

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

If the stye persists despite adequate conservative management:

• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily for a few weeks 1
• Alternative topical option: Mupirocin 2% ointment can be used for minor skin infections and secondarily infected lesions 1
• The frequency and duration should be guided by severity and response, with consideration of rotating antibiotics intermittently to prevent resistant organisms 1

Third-Line Treatment for Persistent or Severe Cases

For cases that remain refractory to topical treatment or show signs of worsening:

• Incision and drainage is recommended as the next step for worsening hordeolum 1
• Oral antibiotics should be initiated if there are signs of spreading infection, with consideration of trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA, though tetracyclines have treatment failure rates up to 21% 1
• Alternative oral antibiotics: Use erythromycin or azithromycin for pregnant women and children under 8 years 1
• Reevaluate in 24-48 hours after starting oral antibiotics to verify clinical response 1

Important Caveats and Pitfalls

Avoid these common mistakes:

• Do not use 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
• Never prescribe tetracyclines to pregnant women or children under 8 years; use erythromycin instead 1
• Use topical corticosteroids with extreme caution and only under ophthalmological supervision, as they can mask infection 1
• Monitor intraocular pressure closely if using steroid-containing drops in patients with advanced glaucoma 1

When to Refer to Ophthalmology

Immediate ophthalmology referral is necessary for:

• Signs of orbital cellulitis or systemic illness 1
• No improvement after incision and drainage plus appropriate antibiotic therapy 1
• Extensive infection or difficulty accessing the lesion (such as inner eyelid location) 1

Long-Term Management Expectations

• Advise patients that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued 1
• Recurrences are common with hordeola, making ongoing preventive eyelid hygiene important 1

Evidence Quality Note

While the American Academy of Ophthalmology provides clear treatment guidelines for hordeolum 1, a Cochrane systematic review found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum, highlighting that current recommendations are based on observational evidence and expert consensus rather than high-quality trials. 2, 3 Despite this limitation, the conservative approach outlined above remains the standard of care and is well-tolerated with minimal risk. 1