What is the recommended management for a stye (hordeolum)?

Stye (Hordeolum) Treatment

For a stye, start immediately with warm compresses applied to the affected eyelid for 5-10 minutes, 3-4 times daily, combined with gentle eyelid cleansing using diluted baby shampoo or commercial eyelid cleaners once or twice daily. 1, 2

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, 2

• Use hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in a microwave for sustained warmth 2

• Ensure water is warm but not hot enough to burn the skin 2

• Perform eyelid cleansing once or twice daily after warm compresses to remove debris and inflammatory material 1, 2

• 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 1, 2

• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used 2

• Follow with gentle vertical massage of the eyelid to help express secretions from the affected gland 1, 2

• Continue this regimen for 2-4 weeks before escalating treatment, as many hordeola drain spontaneously and resolve without further intervention 1, 3, 4

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

• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins once or more times daily (or at bedtime) for a few weeks 1, 2, 5

• Topical antibiotics decrease bacteria from the eyelid margin and provide symptomatic relief 2, 5

• The frequency and duration should be guided by severity and response to treatment 1, 2

• Consider using different antibiotics intermittently to prevent development of resistant organisms 1, 2

• Mupirocin 2% topical ointment is an alternative option for minor skin infections 1

Third-Line Treatment for Persistent or Severe Cases

• For worsening hordeolum requiring surgical intervention, incision and drainage is recommended as the next step 1

• If signs of spreading infection develop (increased redness, warmth, swelling beyond the immediate area), initiate oral antibiotics 1

• Consider trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline) for suspected MRSA infection, though treatment failure rates up to 21% have been reported with tetracyclines 1

• For recurrent styes associated with meibomian gland dysfunction, oral tetracyclines (doxycycline, minocycline, or tetracycline) may be helpful when symptoms are not adequately controlled by eyelid cleansing or topical treatments 1, 2

• For women of childbearing age and children under 8 years, use oral erythromycin or azithromycin instead of tetracyclines 1, 2

• Topical corticosteroids may provide symptomatic relief but should be used with caution and under ophthalmological supervision 1

When to Refer to Ophthalmology

• Immediate referral if signs of orbital cellulitis or systemic illness develop 1
• Refer if no improvement after incision and drainage plus appropriate antibiotic therapy 1
• Consider biopsy if the stye is markedly asymmetric, resistant to therapy, or recurrent in the same location to exclude carcinoma 6, 2
• Reevaluate patients on oral antibiotics in 24-48 hours to verify clinical response 1

Important Clinical Pitfalls and Cautions

• Patients with advanced glaucoma should avoid aggressive pressure on the eyelids during massage, as it may increase intraocular pressure 1, 2

• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleansing 1, 2

• Avoid contact lens wear during active treatment 5

• Long-term antibiotic treatment may result in development of resistant organisms 6, 2

• Advise patients that warm compress and eyelid cleansing treatment may be required long-term, as symptoms often recur when treatment is discontinued 1, 2

• Regular eyelid hygiene is essential for prevention, especially in those prone to recurrent styes or with chronic blepharitis 2

Special Populations

• In pediatric patients, the risk of complications is higher, warranting closer clinical monitoring 1
• Children with recurrent styes or chalazia often have underlying chronic blepharitis or meibomian gland dysfunction that requires treatment 6, 1
• For pregnant women or children under 8 years, avoid tetracyclines and use erythromycin or azithromycin if oral antibiotics are needed 1, 2