What is the best approach to treat a patient with a stye?

How to Treat a Stye (Hordeolum)

Start with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing—this is the first-line treatment recommended by the American Academy of Ophthalmology for most styes. 1, 2, 3

First-Line Conservative Management (Start Here for All Patients)

Warm Compresses

• Apply warm compresses to the affected eyelid 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—ensure the temperature is warm but not hot enough to burn the skin 2
• This treatment softens the material blocking the gland and facilitates natural drainage 1

Eyelid Cleansing and Massage

• 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 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

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 2, 3
• Patients lacking manual dexterity or necessary skill should receive assistance with eyelid cleaning 2

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

Prescribe topical antibiotic ointment if conservative measures fail after 2-4 weeks of consistent treatment. 1, 2, 3

Topical Antibiotic Options

• Bacitracin or erythromycin ointment applied to the eyelid margins 1-3 times daily or at bedtime for a few weeks 1, 2, 3
• Mupirocin 2% topical ointment is an alternative for minor skin infections 1, 3
• The frequency and duration should be guided by severity and response to treatment 2, 3
• Consider using different antibiotics intermittently to prevent development of resistant organisms 3

Important Caveat About Antibiotics

• The Infectious Diseases Society of America confirms that simple, uncomplicated styes should be managed with local measures alone—oral antibiotics should NOT be prescribed for simple styes 1
• 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 Antibiotics

• Consider oral tetracyclines (doxycycline, minocycline, or tetracycline) for patients whose symptoms are not controlled by topical treatments, particularly those with associated meibomian gland dysfunction 1, 2, 3
• Tetracyclines are absolutely contraindicated in pregnancy and children under 8 years due to tooth staining 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 as the next step 2, 3
• Incision and drainage is NOT indicated for an already-draining stye—surgical drainage should be reserved for cases that fail conservative management 1

Red Flags Requiring Immediate Escalation

When to Start Systemic Antibiotics

• 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
• If signs of spreading infection develop, 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

When to Refer to Ophthalmology

• Signs of orbital cellulitis (proptosis, ophthalmoplegia, or vision changes) require immediate ophthalmology referral 1, 3
• If there is no improvement after incision and drainage plus appropriate antibiotic therapy, refer to an ophthalmologist 2, 3
• If the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 2

Long-Term Management and Patient Counseling

• Patients must understand 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
• Avoid aggressive manipulation of the eyelid, particularly in patients with advanced glaucoma 3