Case 26Hordeolum / Chalazion
Clinical Presentation
A 21-year-old student has experienced pain, itching, and a warm red nodule on her upper right lid for the past 4 days. The nodule is shown in the photograph.
Learner Questions
- What is the differential diagnosis of acute, painful lumps on the lid?
- What is your diagnosis in this case?
- In what setting and in which age groups is this problem most commonly seen?
- What is the appropriate management?
Answer Framework
DDx for acute painful lid lumps Setting + age groups
External hordeolum (stye): Staph infection of lash follicle/Zeis gland - painful pustule at lid Most common in adolescents and young adults (hormonal changes -> up sebaceous margin near lash base, points anteriorly through skin. Internal hordeolum: acute secretion + MGD). Predisposing factors: blepharitis (Staph colonization), rosacea, meibomian gland abscess - larger, more painful, points posteriorly through conjunctiva. seborrheic dermatitis, poor lid hygiene, stress, immunosuppression (recurrent hordeola -> Chalazion: chronic STERILE lipogranuloma - painless/firm/nodular in tarsal plate, no screen for DM or HIV). CRITICAL: recurrent chalazion in the SAME LOCATION in an elderly erythema. Preseptal cellulitis: diffuse lid swelling (not focal); systemic Abx required. SGC: patient -> BIOPSY (rule out SGC). recurrent 'chalazion' in elderly = biopsy.
Diagnosis Management
HORDEOLUM - most likely internal hordeolum (meibomian gland abscess). KEY Hordeolum: warm compresses x 10-15 min 3-4x/day + topical antibiotic ointment DISTINCTION: Hordeolum = ACUTE bacterial infection = HOT, PAINFUL, WARM, RED, (erythromycin/bacitracin to lid margin). Oral antibiotics (doxycycline or amoxicillin- TENDER -> responds to antibiotics + warm compresses. Chalazion = CHRONIC sterile clavulanate) if preseptal cellulitis develops. I&D (incision and drainage) if pointing and 2 granuloma = COOL, PAINLESS, FIRM, non-inflamed -> does NOT respond to antibiotics -> 4 fluctuant. Do NOT squeeze. Chalazion: warm compresses x 4-6 weeks (some resolve). requires I&C or steroid injection. Intralesional triamcinolone injection (effective, minimally invasive; risk of skin hypopigmentation in dark skin tones). I&C (incision and curettage) - definitive treatment for persistent chalazia.
Teaching Pearl
Hordeolum vs. chalazion: HOT/PAINFUL/ACUTE = hordeolum (infected) -> warm compresses + antibiotics. COOL/PAINLESS/CHRONIC = chalazion (sterile granuloma) -> warm compresses -> I&C or steroid injection. CRITICAL: recurrent chalazion failing treatment in an elderly patient MUST BE BIOPSIED - sebaceous gland carcinoma kills via pagetoid spread. Always ask: 'Has this been biopsied before?'
Original answer transcript
DDx for acute painful lid lumps Setting + age groups
External hordeolum (stye): Staph infection of lash follicle/Zeis gland - painful pustule at lid Most common in adolescents and young adults (hormonal changes -> up sebaceous
margin near lash base, points anteriorly through skin. Internal hordeolum: acute secretion + MGD). Predisposing factors: blepharitis (Staph colonization), rosacea,
meibomian gland abscess - larger, more painful, points posteriorly through conjunctiva. seborrheic dermatitis, poor lid hygiene, stress, immunosuppression (recurrent hordeola ->
Chalazion: chronic STERILE lipogranuloma - painless/firm/nodular in tarsal plate, no screen for DM or HIV). CRITICAL: recurrent chalazion in the SAME LOCATION in an elderly
erythema. Preseptal cellulitis: diffuse lid swelling (not focal); systemic Abx required. SGC: patient -> BIOPSY (rule out SGC).
recurrent 'chalazion' in elderly = biopsy.
Diagnosis Management
HORDEOLUM - most likely internal hordeolum (meibomian gland abscess). KEY Hordeolum: warm compresses x 10-15 min 3-4x/day + topical antibiotic ointment
DISTINCTION: Hordeolum = ACUTE bacterial infection = HOT, PAINFUL, WARM, RED, (erythromycin/bacitracin to lid margin). Oral antibiotics (doxycycline or amoxicillin-
TENDER -> responds to antibiotics + warm compresses. Chalazion = CHRONIC sterile clavulanate) if preseptal cellulitis develops. I&D (incision and drainage) if pointing and
2 granuloma = COOL, PAINLESS, FIRM, non-inflamed -> does NOT respond to antibiotics -> 4 fluctuant. Do NOT squeeze. Chalazion: warm compresses x 4-6 weeks (some resolve).
requires I&C or steroid injection. Intralesional triamcinolone injection (effective, minimally invasive; risk of skin
hypopigmentation in dark skin tones). I&C (incision and curettage) - definitive treatment
for persistent chalazia.
TEACHING PEARL
Hordeolum vs. chalazion: HOT/PAINFUL/ACUTE = hordeolum (infected) -> warm compresses + antibiotics. COOL/PAINLESS/CHRONIC = chalazion (sterile granuloma) ->
warm compresses -> I&C or steroid injection. CRITICAL: recurrent chalazion failing treatment in an elderly patient MUST BE BIOPSIED - sebaceous gland carcinoma kills
via pagetoid spread. Always ask: 'Has this been biopsied before?'
