What is the relationship between mucosal ulcerations and the long-term use of nasal decongestants?

From the Guidelines

Long-term use of nasal decongestants can cause mucosal ulcerations in the nasal passages, and I strongly recommend discontinuing any topical decongestant that has been used for more than 3-5 days to prevent further damage. The use of topical decongestants, such as oxymetazoline (Afrin) or phenylephrine (Neo-Synephrine), can lead to rebound congestion (rhinitis medicamentosa) and damage to the nasal mucosa, resulting in ulcerations, bleeding, and chronic inflammation 1.

Recommendations for Treatment

• Discontinue topical decongestant use and switch to saline nasal sprays for nasal hygiene
• Consider intranasal corticosteroids like fluticasone (Flonase) or mometasone (Nasonex) for congestion relief
• Apply petroleum jelly or an antibiotic ointment like mupirocin to existing ulcerations using a cotton swab twice daily until healing occurs
• Humidification of living spaces and adequate hydration can also help promote healing

The mechanism behind these ulcerations involves vasoconstriction that reduces blood flow to the nasal tissues, causing tissue damage with prolonged use 1. A recent study also suggests that topical intranasal steroids may have a role in managing viral rhinosinusitis, and could potentially be used to relieve facial pain and nasal congestion, although the magnitude of effect is small 1. If ulcerations persist despite discontinuing decongestants, it is essential to consult a healthcare provider as this could indicate another underlying condition requiring different treatment.

From the FDA Drug Label

When using this product Frequent or prolonged use may cause nasal congestion to recur or worsen temporary discomfort such as burning, stinging, sneezing or an increase in nasal discharge may occur The answer to mucosal ulcerations is not directly addressed in the label.

• Mucosal ulcerations are not mentioned in the label.
• Long term use of nasal decongestants may cause nasal congestion to recur or worsen, but mucosal ulcerations are not mentioned as a potential effect 2

From the Research

Mucosal Ulcerations and Long-Term Nasal Decongestants

• The use of long-term nasal decongestants can lead to rhinitis medicamentosa (RM), a condition characterized by nasal hyperreactivity, mucosal swelling, and tolerance 3.
• Studies have shown that the preservative benzalkonium chloride (BKC) in nasal decongestant sprays can induce mucosal swelling and hyperreactivity, even in healthy subjects 3, 4.
• The combination of vasoactive substances and BKC in nasal decongestant sprays can have a long-term adverse effect on the nasal mucosa, leading to mucosal ulcerations and other complications 3.
• Prolonged use of oxymetazoline, a common ingredient in nasal decongestants, can also induce nasal mucosal swelling and hyperreactivity 5, 4.
• Treatment of rhinitis medicamentosa typically involves withdrawal of the offending nasal decongestant and the use of topical corticosteroids to alleviate symptoms 3, 6.

Adverse Effects of Nasal Decongestants

• The adverse effects of nasal decongestants, including mucosal ulcerations, can be exacerbated by the presence of BKC and other preservatives 4.
• Rebound congestion, nasal hyperreactivity, and tolerance are common complications of long-term nasal decongestant use 3, 5.
• Patients with a history of rhinitis medicamentosa should be cautious when using nasal decongestants, even for short periods, to avoid the risk of rebound congestion and other complications 3.

Treatment and Prevention

• Topical corticosteroids and saline nasal sprays can be effective in treating and preventing rhinitis medicamentosa and other complications of nasal decongestant use 7, 6.
• Patients should be educated on the proper use of nasal decongestants and the potential risks and complications associated with long-term use 3, 4.