What medications are appropriate for managing a hordeolum (stye) of the eyelid?

Treatment of Hordeolum (Stye)

For a hordeolum of the eyelid, start with warm compresses applied 3-4 times daily for 5-10 minutes combined with eyelid hygiene using diluted baby shampoo or commercial eyelid cleaners, and if there is no improvement after 2-4 weeks, add topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins. 1

First-Line Conservative Management

The initial approach focuses on promoting natural drainage and reducing inflammation:

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily to soften crusts, warm meibomian secretions, and promote spontaneous drainage 1
• Perform eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
• Gentle vertical massage of the eyelid should be performed for posterior blepharitis or meibomian gland involvement to help express secretions 1

This conservative approach is appropriate because many hordeola drain spontaneously and resolve without additional intervention 2, 3. However, patients should understand that warm compress and eyelid cleansing may be required long-term, as symptoms often recur when treatment is discontinued 1.

Second-Line Treatment (After 2-4 Weeks Without Improvement)

If conservative measures fail to resolve the hordeolum:

• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily for a few weeks 1, 4
• The frequency and duration should be guided by severity and response, with consideration of rotating different antibiotics intermittently to prevent development of resistant organisms 1, 4

Erythromycin is particularly valuable as it has no cross-reactivity with sulfonamides and provides effective bacterial load reduction 4. Bacitracin is another safe option that can be applied directly to the eyelid margins 1 to 3 times daily after carefully removing all scales and crusts 4.

Persistent or Severe Cases Requiring Escalation

For hordeola that worsen or fail to respond to topical treatment:

• Incision and drainage is recommended as the next step for worsening upper eyelid hordeolum 1
• Oral antibiotics should be initiated if there are signs of spreading infection, with consideration of doxycycline, minocycline, or tetracycline for patients with meibomian gland dysfunction whose symptoms are not adequately controlled by eyelid cleansing or topical treatments 1
• Alternative oral antibiotics such as erythromycin or azithromycin may be used for women of childbearing age and children under 8 years, as tetracyclines are contraindicated in these populations 1, 4
• Topical corticosteroids may provide symptomatic relief but should be used with caution and under ophthalmological supervision 1

Patients started on oral antibiotics should be reevaluated in 24-48 hours to verify clinical response 1.

When to Refer to Ophthalmology

Immediate referral is necessary when:

• Signs of orbital cellulitis or systemic illness are present 1
• No improvement occurs after incision and drainage plus appropriate antibiotic therapy 1
• The stye is in an area difficult to treat, such as the inner eyelid 1

Critical Pitfalls and Special Considerations

Avoid aggressive manipulation of the eyelid, particularly in patients with advanced glaucoma, as it may increase intraocular pressure 1, 4. Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1.

For pregnant women or children under 8 years, avoid tetracyclines entirely and use erythromycin or azithromycin if oral antibiotics are needed 1, 4. In patients with advanced glaucoma, use steroid-containing drops with extreme caution and monitor intraocular pressure closely 1, 5.

Recurrent styes or chalazia indicate underlying chronic blepharitis or meibomian gland dysfunction that requires long-term management 1. Underlying dermatologic conditions such as rosacea, atopic dermatitis, or seborrheic dermatitis should be addressed, as they predispose patients to recurrent styes 1.

Evidence Quality Note

While the above recommendations come from high-quality guidelines 1, 4, it is important to note that Cochrane systematic reviews found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum 2, 3. The treatment recommendations are therefore based on expert consensus and observational evidence rather than high-quality randomized trials. One small randomized trial from China showed ear-apex blood-letting (acupuncture) was more effective than topical antibiotics, but this evidence has limited generalizability to non-Chinese populations 6, 7.