How should a stye (hordeolum) be treated?

Treatment of Stye (Hordeolum)

Start with warm compresses (5-10 minutes, 3-4 times daily) and eyelid hygiene as first-line treatment; reserve topical antibiotics for cases that fail to improve after 2-4 weeks of conservative management. 1, 2

First-Line Conservative Management

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
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or homemade bean/rice bags heated in the microwave for sustained warmth 1, 3
• Critical safety point: Ensure the compress is warm but not hot enough to burn the skin 1, 3

Eyelid Hygiene:

• After warm compresses, perform gentle eyelid cleansing by rubbing 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, 3
• Eye cleaners containing hypochlorous acid (0.01%) have strong antimicrobial effects and can be used 1, 3
• Perform gentle vertical massage of the eyelid to help express the contents of the affected gland 1, 2
• Continue eyelid cleansing once or twice daily, as regularly performed hygiene often reduces symptoms and prevents recurrence 1, 2

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

Topical Antibiotics:

• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily or at bedtime for a few weeks 1, 2, 3
• Erythromycin ophthalmic ointment can be applied up to six times daily depending on severity 4
• Topical antibiotics provide symptomatic relief and decrease bacterial load from the eyelid margin 2, 3
• Mupirocin 2% topical ointment is an alternative option for minor skin infections 2

Severe or Recurrent Cases

Oral Antibiotics:

• For patients with meibomian gland dysfunction whose symptoms are not adequately controlled by topical treatments, consider oral tetracyclines (doxycycline, minocycline, or tetracycline) 1, 2
• For women of childbearing age and children under 8 years: Use oral erythromycin or azithromycin instead of tetracyclines, as tetracyclines are contraindicated in these populations 1, 2

Surgical Intervention:

• For worsening hordeolum despite conservative management, incision and drainage is recommended 2
• If there are signs of spreading infection with incision and drainage, initiate oral antibiotics with consideration of trimethoprim-sulfamethoxazole or tetracycline for suspected MRSA 2

Critical Safety Considerations and Pitfalls

Patient-Specific Precautions:

• Patients with neurotrophic corneas: Provide proper counseling to avoid injury to corneal epithelium during eyelid cleansing 1, 2, 3
• Patients with advanced glaucoma: Advise against aggressive pressure on the eyelids, as it may increase intraocular pressure 1, 2, 3
• Patients lacking manual dexterity: Eyelid cleaning can be dangerous if the patient lacks the necessary skill or judgment to perform the task safely 1, 3

Antibiotic Resistance:

• Long-term antibiotic treatment may result in the development of resistant organisms 5, 1, 3
• Consider using different antibiotics intermittently to prevent resistance 2

Red Flags Requiring Biopsy:

• If a stye is markedly asymmetric, resistant to therapy, or recurrent in the same location, consider biopsy to exclude the possibility of carcinoma 1, 3

Long-Term Management and Prevention

Chronic Management:

• Patients should understand that warm compress and eyelid cleansing treatment may be required long-term, as symptoms often recur when treatment is discontinued 5, 1, 2, 3
• Address underlying dermatologic conditions such as rosacea, atopic dermatitis, or seborrheic dermatitis, as they predispose patients to recurrent styes 2
• For recurrent styes, daily eyelid cleansing may help prevent recurrence 1

Prevention Strategies:

• Regular eyelid hygiene, especially for those prone to styes or with chronic blepharitis 1
• Proper contact lens hygiene and avoiding wearing contact lenses longer than recommended 1
• Avoid sharing eye makeup and replace eye makeup regularly 1

When to Refer to Ophthalmology

• If there is no improvement after incision and drainage plus appropriate antibiotic therapy 2
• If there are signs of orbital cellulitis or systemic illness, immediate referral is necessary 2
• If the stye is in an area difficult to treat, such as the inner eyelid 2

Special Populations

• Pediatric patients: The risk of complications from styes is higher, warranting closer clinical monitoring 2
• Pregnant women: Avoid tetracyclines and consider alternatives like erythromycin if oral antibiotics are needed 2