How should I treat a hordeolum (stye)?

Hordeolum Treatment

For acute hordeolum (stye), start with warm compresses applied 3-4 times daily for 10-15 minutes combined with topical antibiotic drops or ointment, which resolves most cases within 5-14 days without surgical intervention. 1, 2

Initial Conservative Management (First-Line)

The American Academy of Ophthalmology recommends this approach for all acute hordeola: 1, 2

• Apply warm compresses to the affected eyelid for 10-15 minutes, 3-4 times daily to promote spontaneous drainage and accelerate resolution 1, 2
• Prescribe topical antibiotic drops or ointment to treat the primary staphylococcal infection and protect against secondary bacterial infection 1, 2
• Institute regular eyelid hygiene measures including cleaning eyelid margins with mild soap or commercial eyelid cleansers 2
• Perform gentle massage of the affected area after warm compresses to help express the obstructed gland 2

Critical instruction: Never squeeze or attempt to "pop" the hordeolum, as this spreads infection. 2

When to Escalate Treatment

If no improvement occurs after 48 hours of appropriate conservative therapy, modify your approach: 2

• Consider oral antibiotics for severe cases with spreading infection or systemic symptoms 2
• Azithromycin ophthalmic solution has demonstrated complete resolution in all treated cases of internal hordeolum in retrospective series 1

Managing Underlying Conditions

Since hordeolum is frequently associated with bacterial blepharitis, address this aggressively: 1, 2

• Treat underlying blepharitis with more aggressive eyelid hygiene regimens for recurrent hordeola 2
• Evaluate for meibomian gland dysfunction in patients with recurrent disease 2
• Consider ocular rosacea as a contributing factor requiring systemic treatment 2

Special Populations Requiring Modified Approach

Immunocompromised patients (diabetes, HIV, chemotherapy): 2

• Require systemic oral antibiotics in addition to topical therapy 2
• Avoid aggressive eyelid manipulation to reduce risk of serious secondary infections 2
• These patients are prone to more aggressive infections requiring heightened clinical vigilance 2

Pediatric patients: 3

• Extend conservative management period before considering surgical intervention 3
• Children with history of styes have increased risk of developing adult rosacea 1

Red Flags Requiring Ophthalmology Referral

Immediately refer for ophthalmologic evaluation if: 1, 4, 2

• Marked asymmetry, resistance to therapy, or unifocal recurrent lesions (raises suspicion for sebaceous carcinoma) 1, 2
• Eyelid margin distortion, lash loss (madarosis), or ulceration 1
• Unilateral chronic blepharitis unresponsive to therapy 1
• Recurrence in the same location, especially in elderly patients 1, 4
• Moderate to severe pain (may indicate secondary infection or atypical presentation) 4

Common Pitfalls to Avoid

• Failing to distinguish hordeolum from chalazion: Hordeolum has rapid onset with acute inflammation and pain, while chalazion has gradual onset and is painless 1, 2
• Missing underlying chronic blepharitis that predisposes to recurrent hordeola 2
• Overlooking sebaceous carcinoma in recurrent unilateral disease resistant to therapy 2

Evidence Quality Note

The evidence base for hordeolum treatment is notably weak—no randomized controlled trials exist comparing interventions to placebo or observation. 5, 6 Current recommendations are based primarily on expert consensus from the American Academy of Ophthalmology guidelines. 1, 2 Despite this limitation, the conservative approach with warm compresses and topical antibiotics remains standard practice, as most hordeola resolve spontaneously within 5-14 days. 1

Additional Patient Instructions

• Discontinue eye makeup during active infection 2
• Avoid reusing or sharing personal items (razors, linens, towels) that contact the infected area 7
• Maintain good hand hygiene with soap and water or alcohol-based gel after touching the affected area 7