What is the recommended treatment for a cold?

Treatment for the Common Cold

The common cold requires only symptomatic management with combination antihistamine-decongestant-analgesic products providing the most effective relief, while antibiotics should never be used as they provide no benefit and contribute to antimicrobial resistance. 1, 2

Core Treatment Approach

The common cold is a self-limiting viral illness that typically resolves in 7-10 days, though up to 25% of patients may have symptoms persisting for 14 days—this is normal and does not indicate bacterial infection. 2, 3

First-Line Symptomatic Treatment

For patients with multiple cold symptoms, combination antihistamine-decongestant-analgesic products are superior to single agents, with approximately 1 in 4 patients experiencing significant improvement (odds ratio of treatment failure 0.47; NNTB 5.6). 1, 2

For targeted symptom relief:

• Nasal congestion: Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit, or topical nasal decongestants for more effective relief—but limit topical use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 1, 2

• Runny nose (rhinorrhea): Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion. 1, 2

• Pain, fever, headache: NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing. 4, 1, 2 Acetaminophen/paracetamol may help nasal obstruction and rhinorrhea but does not improve other symptoms like sore throat, malaise, or cough. 4, 5

• Cough: Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard OTC doses are likely subtherapeutic. 2 Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit. 2

Evidence-Based Adjunctive Therapies

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—there is no benefit if symptoms are already established beyond 24 hours. 4, 1, 2 Potential side effects include bad taste and nausea. 1

Vitamin C may be worthwhile to try on an individual basis given its consistent effect on duration and severity of colds, low cost, and safety profile. 4

Nasal saline irrigation provides modest symptom relief, particularly beneficial in children, by helping dilute secretions and facilitate elimination. 4, 1, 2

What Does NOT Work (Critical Pitfalls to Avoid)

Antibiotics have no benefit for uncomplicated common cold and are associated with significant adverse effects while contributing to antimicrobial resistance. 4, 1, 2, 3 This is true even when symptoms persist beyond 7-10 days, as prolonged symptoms do not automatically indicate bacterial infection. 3

Intranasal corticosteroids do not provide symptomatic relief from the common cold. 4, 1, 2

Echinacea products have not been shown to provide significant benefits for treating colds, though some products may have weak benefit of questionable clinical relevance. 4

Steam/heated humidified air has no proven benefits or harms. 4

Antihistamines alone (non-sedating, newer generation) have limited benefit and no clinically significant effect on nasal obstruction, rhinorrhea, or sneezing. 1, 2

When to Suspect Bacterial Complications

Only 0.5-2% of viral upper respiratory infections develop bacterial complications. 2, 3 Suspect bacterial rhinosinusitis only if at least 3 of the following 5 criteria are present: 3

• Discolored (purulent) nasal discharge
• Severe local pain (especially unilateral facial pain)
• Fever >38°C (100.4°F)
• "Double sickening" pattern (initial improvement followed by worsening)
• Elevated inflammatory markers

Common pitfall: 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. 2

Red Flags Requiring Medical Evaluation

• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement 2, 3
• Severe unilateral facial pain 2, 3
• "Double sickening" pattern 2, 3
• Hemoptysis (any amount) 2
• Acute breathlessness 2

Management of Prolonged Symptoms (>10 Days)

Symptoms persisting beyond 10 days without improvement classify as post-viral rhinosinusitis. 3 Continue symptomatic treatment with combination products and consider adding intranasal corticosteroids if symptom reduction is necessary. 4, 3 Antibiotics remain unjustified unless criteria for bacterial infection are met. 3

Special Populations

Children: Acetaminophen/paracetamol for fever and pain; honey for cough (only in children ≥1 year old); avoid OTC cough and cold medications in children younger than 4 years. 2, 6

Pregnant women: Acetaminophen/paracetamol is first-line for pain and fever. 2