How to treat the common cold accurately?

How to Treat the Common Cold

The common cold requires only symptomatic management with combination antihistamine-decongestant-analgesic products providing the most effective relief—antibiotics are never indicated and should not be prescribed. 1, 2

Core Treatment Principles

The common cold is a self-limited viral illness that typically resolves within 7-10 days, though up to 25% of patients may experience symptoms for up to 14 days. 1, 3 Symptomatic therapy is the only appropriate management strategy, as antibiotics provide no benefit and significantly increase the risk of adverse effects. 1, 4

First-Line Symptomatic Treatment

Combination Products (Most Effective)

Combination antihistamine-analgesic-decongestant products provide superior symptom relief compared to single agents, with approximately 1 in 4 patients experiencing significant improvement. 1, 2, 3 These combinations have an odds ratio of treatment failure of 0.47 (95% CI 0.33-0.67), translating to a number needed to treat of 5.6. 3

• First-generation antihistamines (such as brompheniramine) combined with sustained-release pseudoephedrine effectively reduce congestion and rhinorrhea 3
• Benefits must be weighed against potential side effects including drowsiness and dry mouth 1
• Important caveat: Antihistamines alone have more adverse effects than benefits and should not be used as monotherapy 1

Analgesics for Pain and Fever

NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are highly effective for multiple cold symptoms including headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 1, 2, 3

• Acetaminophen/paracetamol may help relieve nasal obstruction and rhinorrhea but does not improve other symptoms like sore throat, malaise, sneezing, or cough 2, 3, 5
• NSAIDs should be used at the lowest effective dose for the shortest duration necessary 6
• Critical warning: NSAIDs increase risk of cardiovascular events, GI bleeding, and should be avoided in patients with recent heart attack, active ulcer disease, or after 30 weeks of pregnancy 6

Decongestants

Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit for nasal congestion but should only be used short-term (3-5 days maximum) to avoid rebound congestion. 1, 2, 3

• Topical nasal decongestants are effective but carry the same risk of rhinitis medicamentosa (rebound congestion) with prolonged use 3
• Short-term use is symptomatic only and does not influence disease course 1

Ipratropium Bromide

Intranasal ipratropium bromide effectively reduces rhinorrhea but has no effect on nasal congestion. 1, 2, 3

• May cause minor side effects such as nasal dryness 2
• Does not improve other cold symptoms 1

Evidence-Based Adjunctive Therapies

Zinc Lozenges (Time-Critical)

Zinc lozenges (≥75 mg/day of zinc acetate or zinc gluconate) significantly reduce cold duration BUT only if started within 24 hours of symptom onset. 1, 2, 3

• Must be continued throughout the cold at the specified dose 1
• Critical timing: No benefit if symptoms are already established beyond 24 hours 2, 7
• Potential side effects include bad taste and nausea 1, 2

Nasal Saline Irrigation

Nasal saline irrigation provides modest symptom relief, particularly beneficial in children. 1, 2, 3

• Helps dilute secretions and facilitate elimination 3
• Safe with no significant adverse effects 1

Vitamin C

Vitamin C may be worth trying on an individual basis given its consistent effect on reducing duration and severity of colds, low cost, and excellent safety profile. 1, 2

• More effective as prophylaxis than treatment 1
• Individual response varies 1

Treatments That Do NOT Work (Avoid These)

Antibiotics

Antibiotics have no benefit for uncomplicated common cold, provide no reduction in symptoms or duration, and significantly increase adverse effects. 1, 3, 4

• Number needed to harm from antibiotics is 8, while number needed to treat is 18 for acute rhinosinusitis 1
• Antibiotics do not prevent bacterial complications such as sinusitis, asthma exacerbation, or otitis media 1
• Inappropriate use contributes to antimicrobial resistance 3, 4

Intranasal Corticosteroids

Intranasal corticosteroids have no evidence supporting their use for symptomatic relief from the common cold. 1, 3

• May be beneficial for post-viral rhinosinusitis (symptoms >10 days) but not for acute cold symptoms 1, 7

Other Ineffective Treatments

• Echinacea products do not provide significant benefits 1, 2
• Steam/heated humidified air has no proven benefits 1, 2
• Non-sedating (newer generation) antihistamines are ineffective 3
• Homeopathic products show no benefit over placebo 1

Pediatric-Specific Considerations

Over-the-counter cough and cold medications should not be used in children younger than 4 years due to potential harm without proven benefit. 1

• Acetaminophen/paracetamol is appropriate for fever and pain in children 3
• Honey (for children ≥1 year old) is effective for cough 8
• Nasal saline irrigation is particularly beneficial in children 1, 2

When to Reassess or Refer

Normal Duration

• Symptoms typically last 7-10 days 1, 3
• Up to 25% of patients have symptoms for 14 days—this is normal and does not indicate bacterial infection 3, 7

Warning Signs Requiring Medical Evaluation

Patients should be advised to follow up if symptoms worsen or exceed expected recovery time. 1

• Fever >39°C (102.2°F) and purulent nasal discharge or facial pain lasting ≥3 consecutive days 1
• "Double sickening" pattern (initial improvement followed by worsening) 1, 3, 7
• Severe unilateral facial pain 3, 7
• Symptoms persisting >10 days without any improvement may represent post-viral rhinosinusitis 7
• Hemoptysis, acute breathlessness, or suspected foreign body inhalation require immediate evaluation 3

Bacterial Rhinosinusitis Criteria

Bacterial infection should only be suspected if at least 3 of 5 criteria are present: discolored (purulent) nasal discharge, severe local pain, fever >38°C (100.4°F), "double sickening" pattern, or elevated inflammatory markers. 3, 7

• Only 0.5-2% of viral upper respiratory infections develop bacterial complications 3, 7
• Patients who are seriously ill, deteriorate despite treatment, or have recurrent episodes should be referred to a specialist 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uncomplicated cold symptoms, even when prolonged beyond 7 days 1, 3, 7
• Do not use decongestants for more than 3-5 days to avoid rebound congestion 3
• Do not recommend zinc if symptoms have been present for more than 24 hours as it will not be effective 2, 7
• Do not diagnose bacterial sinusitis in the first 10 days of symptoms—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 3
• Manage patient expectations by explaining that symptoms can last up to 2 weeks and that this is normal 1, 3

Prevention Counseling

The most efficient means of transmission is direct hand contact; appropriate handwashing is the best method to reduce spread. 1

• Regular, moderate-intensity exercise may have an effect on prevention 1
• Prophylactic probiotics and vitamin C may reduce incidence in some populations 1