Treatment of Runny Nose (Rhinorrhea)
For runny nose, intranasal corticosteroids are the most effective first-line treatment and should be started immediately, as they provide superior relief for rhinorrhea compared to all other medication classes. 1, 2
First-Line Treatment Approach
Intranasal Corticosteroids (Primary Recommendation)
- Intranasal corticosteroids are the most effective monotherapy for rhinorrhea in both allergic and nonallergic rhinitis, providing superior symptom control compared to antihistamines or other agents. 1, 2
- Available options include fluticasone furoate (ages ≥2 years), ciclesonide (ages ≥6 years), and mometasone (ages ≥2 years), all available by prescription. 3
- These medications work through broad anti-inflammatory mechanisms and are the most potent long-term pharmacologic treatment. 4
- Direct the spray away from the nasal septum to avoid mucosal erosions and potential septal perforations. 1
When Rhinorrhea is the Predominant Symptom
- Intranasal anticholinergics (ipratropium bromide) are particularly effective for isolated rhinorrhea but have no effect on other nasal symptoms like congestion or sneezing. 3, 2
- Combining ipratropium bromide with an intranasal corticosteroid is more effective than either drug alone for treating rhinorrhea, without increased adverse events. 3, 2
- Side effects are minimal, though nasal membrane dryness may occur. 3
Second-Line Options
Antihistamines
- Second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) are effective for rhinorrhea associated with allergic rhinitis and are preferred over first-generation agents due to less sedation. 1, 2, 5
- Intranasal antihistamines (such as azelastine) may be considered for first-line treatment and are equal to or superior to oral antihistamines for seasonal allergic rhinitis. 3, 2
- For moderate to severe symptoms, combining intranasal corticosteroid with intranasal antihistamine provides greater efficacy than either alone. 1, 2
- Antihistamines are more effective for sneezing, itching, and runny nose than for nasal congestion. 6, 7
Adjunctive Treatments
- Nasal saline irrigation is beneficial for chronic rhinorrhea when used as sole therapy or adjunctive treatment, with minimal side effects. 3, 1, 2
- Oral anti-leukotriene agents (montelukast) alone or combined with antihistamines have proven useful in allergic rhinitis. 3, 2
Critical Pitfalls to Avoid
Medications to Avoid or Use with Caution
- Never use first-generation antihistamines (chlorpheniramine, diphenhydramine) as they cause significant sedation, performance impairment, and anticholinergic effects including urinary retention and cognitive impairment. 3, 2
- Limit intranasal decongestants to less than 3-10 days to prevent rhinitis medicamentosa (rebound congestion), which can worsen rhinorrhea. 1, 2, 8
- Avoid recurrent parenteral corticosteroids, which are contraindicated due to long-term side effects. 3, 2
- Oral decongestants (pseudoephedrine, phenylephrine) primarily treat congestion, not rhinorrhea, and should be used cautiously in patients with hypertension, cardiac arrhythmia, glaucoma, or hyperthyroidism. 3, 2, 9
Treatment Algorithm Based on Rhinitis Type
Allergic Rhinitis with Rhinorrhea
- Start with intranasal corticosteroids as first-line therapy. 1, 2
- Add second-generation oral antihistamine if rhinorrhea persists with sneezing and itching. 1, 2
- For moderate to severe symptoms, combine intranasal corticosteroid with intranasal antihistamine. 1, 2
- Consider allergen immunotherapy for patients with demonstrable IgE antibodies to relevant allergens, as it can modify disease natural history. 3, 1, 2
Nonallergic Rhinitis with Rhinorrhea
- Start with intranasal corticosteroids. 2
- Add ipratropium bromide specifically for rhinorrhea, as oral antihistamines are ineffective in nonallergic rhinitis. 2
- Intranasal antihistamines are also effective for nonallergic rhinitis. 3, 2