What is the recommended management for a chalazion?

Chalazion Management

First-Line Treatment: Conservative Management

Start all chalazia with warm compresses applied for 5-10 minutes, 3-4 times daily, combined with eyelid hygiene and gentle massage—this approach resolves approximately 80% of cases within 4-6 weeks. 1, 2

Conservative Treatment Protocol

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily, to promote drainage of the obstructed meibomian gland 1, 2
• Perform gentle massage of the affected area immediately after warm compresses to help express the obstructed gland 1, 2
• Institute eyelid hygiene by cleaning the eyelid margins with mild soap or commercial eyelid cleansers 1, 2
• Conservative therapy alone achieves approximately 80% resolution rates 3

Critical Timing Consideration

• Do not continue conservative management beyond 4-6 weeks without reassessment, as prolonged conservative treatment delays diagnosis of potential sebaceous carcinoma, particularly in elderly patients 1, 2

Second-Line Treatment: Intralesional Steroid Injection

For chalazia persisting after 4-6 weeks of conservative therapy, inject triamcinolone acetonide directly into the lesion before considering surgery. 1, 2

Steroid Injection Details

• Intralesional triamcinolone acetonide achieves a 93.8% success rate compared to 58.3% with conservative management alone 1
• In pediatric patients, 75% of chalazia resolve after a single injection, with most remaining cases responding to a second or third injection 4
• Re-evaluate within a few weeks after injection to assess response and check intraocular pressure 1

Common Pitfall

• Hypopigmentary skin changes can occur at the injection site, particularly with transcutaneous injections 1, 4

Surgical Management

Reserve incision and curettage for chalazia that fail steroid injection or have features suggesting infection. 4

Surgical Indications

• Failure of conservative management and steroid injection 1, 2
• Infected chalazia requiring drainage 4
• Large, recurrent, or multiple chalazia may benefit from combined incision, curettage, and intralesional steroid injection (100% resolution rate in pediatric studies) 4

CRITICAL RED FLAGS: When to Biopsy

Always biopsy recurrent chalazia in the same location, especially in elderly patients, as sebaceous carcinoma commonly masquerades as chalazion. 1, 2, 5

Mandatory Biopsy Indications

• Recurrence in the same location, particularly in elderly patients 1, 2, 5
• Marked asymmetry or resistance to standard therapy 1, 2
• Unifocal recurrent chalazia unresponsive to therapy 1
• Atypical features including eyelid margin distortion, focal lash loss (madarosis), or ulceration 1, 5
• Unilateral chronic blepharitis unresponsive to therapy 1, 5
• History of multiple excisions at the same site 5
• Cutaneous squamous cell carcinoma can also masquerade as chalazion, though this is exceedingly rare 6

Addressing Underlying Conditions

Treat any associated bacterial blepharitis or meibomian gland dysfunction before addressing the chalazion, as these are common predisposing factors. 1, 2

Evaluation and Treatment

• Evaluate for meibomian gland dysfunction, rosacea, or seborrheic dermatitis in patients with recurrent chalazia 1, 2, 5
• Institute regular eyelid hygiene for patients with blepharitis 1, 2, 5
• Consider systemic antibiotics for severe underlying blepharitis 1
• Treat underlying skin conditions (rosacea, seborrheic dermatitis) to prevent recurrence 1, 2, 5

Emerging Treatment Options

Intense pulsed light (IPL) with meibomian gland expression shows promise for recurrent multiple chalazia resistant to conventional therapy. 1, 2

IPL Considerations

• IPL demonstrates high Demodex eradication rates and improved meibum quality compared to topical treatments 1
• Use IPL with caution in darkly pigmented individuals (above Fitzpatrick skin type IV) due to risk of burns and pigmentation changes 1, 2
• Vectored thermal pulsation therapy may improve meibomian gland function 1

Pediatric Considerations

Children with chalazia should be evaluated for chronic blepharokeratoconjunctivitis, which often presents with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation. 1, 2, 5

Pediatric Red Flags Requiring Ophthalmology Referral

• Visual loss 1, 5
• Moderate to severe pain (may indicate acute hordeolum, secondary infection, or atypical presentation) 1, 5
• Severe or chronic redness 1, 5

Prevention Strategies

• Maintain regular eyelid hygiene for patients prone to recurrent chalazia, especially those with blepharitis or meibomian gland dysfunction 1, 2, 5
• Avoid eye makeup during active inflammation 1, 5
• Treat underlying conditions proactively 1, 2, 5