Stye (Hordeolum) - Treatment in Adults and Children

External hordeolum showing erythema and swelling at the eyelid margin.

What is a Stye?

• External hordeolum - abscess of a gland of Zeis (sebaceous) or Moll (sweat) gland at the eyelash margin; presents as a pustule at the lid margin
• Internal hordeolum - abscess of the meibomian gland; pustule points on the inner (conjunctival) surface of the eyelid

Treatment - Core Principles (Same in Adults and Children)

Step 1 - Warm Compresses (First-line for Everyone)

• Apply a warm, moist compress to the closed eyelid
• Duration: 10-20 minutes per session
• Frequency: 3-5 times per day
• One practical method: soak a clean washcloth in very hot water and replace as it cools, keeping it warm over 15-20 minutes
• Heat promotes drainage and spontaneous resolution

• Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1511
• Rosen's Emergency Medicine, p. 893

Step 2 - Topical Antibiotics (Moderate/Persistent Cases)

• Tintinalli's Emergency Medicine, p. 1581
• Wills Eye Manual, p. 382

Step 3 - Systemic (Oral) Antibiotics (Cellulitis or Severe Cases)

• Dicloxacillin (antistaphylococcal penicillin)
• Cephalosporins (e.g., cephalexin)
• Doxycycline 20-50 mg daily for adults with recurrent/multiple hordeola or associated ocular rosacea (note: doxycycline is generally avoided in children under 8 years)
• Roberts and Hedges', p. 1511

Step 4 - Incision and Drainage (I&D) (Unresponsive Cases)

• Indications: Failure to respond to conservative therapy, large abscess
• Internal stye: Evert the eyelid and nick the pustule on the inner conjunctival surface
• External stye: Nick at the lid margin
• More formal I&D may be performed by an ophthalmologist in resistant cases
• Roberts and Hedges', p. 1511
• Wills Eye Manual, p. 383

Special Notes for Children

• The treatment is the same as in adults - warm compresses are the primary approach
• Children's Hospital guidelines consistently recommend warm compresses + hygiene (daily face washing, no eye makeup during infection)
• Doxycycline should be avoided in children under 8 years due to tooth discoloration risk; use erythromycin or amoxicillin-clavulanate instead
• Children may be less cooperative with compresses - parents can use a warm, damp face cloth while the child watches TV to ensure adequate duration
• In children with pre-septal cellulitis complicating a stye, distinguishing pre-septal from post-septal (orbital) cellulitis is especially important, as the orbital septum is incompletely formed, making spread more likely and differentiation harder clinically - CT imaging and pediatric/ophthalmology consultation are indicated in uncertain cases
• Rosen's Emergency Medicine, p. 894

What NOT to Do

• Do not squeeze or pop a stye - this can spread infection
• Do not wear eye makeup until fully healed
• Do not wear contact lenses during an active infection
• Do not use topical corticosteroids alone for a hordeolum (reserved for chalazion, not active infection)

When to Refer to Ophthalmology

• No improvement after 3-4 weeks of medical therapy
• Worsening despite antibiotics (concern for preseptal cellulitis)
• Need for formal I&D
• Recurrent chalazia/hordeola in older patients (rule out sebaceous cell carcinoma)
• Proptosis, pain on eye movement, or restricted eye movement (suggests post-septal/orbital cellulitis - urgent referral)

Chalazion vs. Hordeolum - Quick Distinction

• Wills Eye Manual, p. 381; Tintinalli's Emergency Medicine, p. 1581