Is steroid nasal spray (corticosteroid) effective for treating acute viral rhinitis?

Steroid Nasal Spray for Acute Viral Rhinitis

Intranasal corticosteroids provide modest symptom relief for acute viral rhinitis and can be used when symptom reduction is considered necessary, though the effect is small and the condition is self-limiting. 1

Evidence-Based Recommendation

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 provides Level 1a evidence that nasal corticosteroids are effective in reducing total symptom scores in adults with acute post-viral rhinosinusitis, but emphasizes the effect size is small and there is no demonstrated impact on quality of life. 1 Based on this moderate-quality evidence, EPOS 2020 advises prescribing nasal corticosteroids only when reduction of symptoms is considered necessary, given that acute viral rhinitis is self-limiting. 1

Specific Dosing Regimens

When you decide to prescribe intranasal corticosteroids for acute viral rhinitis, use these evidence-based regimens:

Adults

• Fluticasone propionate: 110 μg once or twice daily for 14 days 1, 2
• Mometasone furoate: 200 μg once or twice daily for 15 days 1, 2
• Budesonide: 50 μg per nostril twice daily for 3 weeks 1, 2

Children

• Fluticasone propionate: 50 μg per nostril twice daily for 14 days 2
• Budesonide: 50 μg per nostril twice daily for 3 weeks 1, 2

What the Evidence Shows

Symptom reduction: Meta-analyses demonstrate that intranasal corticosteroids significantly reduce major symptom scores, particularly nasal congestion, compared to placebo. 1 Studies show faster time to symptom improvement and reduced percentage of days with minimal symptoms. 1

Specific symptoms improved: Nasal congestion shows the most consistent improvement across studies. 1 Facial pain/pressure, postnasal drip, and overall symptom scores also improve, though effects are modest. 1

What doesn't improve: Quality of life measures (SNOT-20) show no significant improvement. 1 Time to complete cure may not differ significantly from placebo in some studies. 1

Safety profile: No difference in adverse events compared to placebo, and no increased need for antibiotics. 1 Local side effects (epistaxis, nasal irritation) occur in approximately 9-21% of patients but are generally minor. 3

Clinical Decision Algorithm

Use intranasal corticosteroids when:

• Symptoms are bothersome enough that the patient seeks relief beyond supportive care 1, 4
• Nasal congestion is the predominant symptom 1
• Symptoms have persisted beyond 5 days (to distinguish from simple common cold) 1

Do NOT use intranasal corticosteroids as routine first-line for all cases because the effect is small and the condition resolves spontaneously. 1

First-Line Alternatives

The American Academy of Otolaryngology-Head and Neck Surgery recommends considering these options alongside or instead of intranasal steroids: 4

• Nasal saline irrigation: Relieves congestion and facilitates clearance of secretions 1, 4
• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever 4
• Adequate hydration: Helps thin secretions 4

What NOT to Do

Avoid systemic corticosteroids: EPOS 2020 provides Level 1a evidence advising against systemic corticosteroids for acute viral rhinitis. 1 While they show a small effect on facial pain at days 4-7, there is no benefit on recovery at 7-14 days, and potential harms outweigh benefits. 1

Do not prescribe antibiotics: They are ineffective for viral illness, provide no symptom relief, and contribute to antimicrobial resistance. 1, 4 Only consider antibiotics if symptoms persist beyond 7-10 days without improvement or worsen after initial improvement, suggesting bacterial superinfection. 4

Limit topical decongestants: Use for no more than 3-5 days to avoid rebound congestion (rhinitis medicamentosa). 4

Special Populations

Children under 3 years: Avoid decongestants and antihistamines due to potential adverse effects. 4 Evidence for intranasal corticosteroids in children is very low quality, and EPOS 2020 cannot make a firm recommendation. 1

Patients with chronic conditions: Monitor closely in patients with asthma or other respiratory conditions. 4

Common Pitfalls

• Overprescribing for every case of viral rhinitis: Remember this is a self-limiting condition; reserve treatment for symptomatic relief when necessary. 1
• Underutilizing simple measures: Saline irrigation and hydration provide significant relief without medication. 4
• Incorrect technique: Patients must be educated on proper nasal spray administration to maximize benefit and minimize local irritation. 5
• Setting unrealistic expectations: Inform patients that symptom reduction will be modest, not complete resolution. 1