What is the recommended management for a patient with rhinitis?

Rhinitis Management

Intranasal corticosteroids are the first-line treatment for patients with moderate to severe or persistent rhinitis, while second-generation oral antihistamines or intranasal antihistamines are appropriate for mild intermittent symptoms. 1, 2

Initial Classification and Treatment Selection

The management approach depends on distinguishing allergic from nonallergic rhinitis and assessing symptom severity:

For Allergic Rhinitis

Mild intermittent symptoms (< 4 days/week or < 4 weeks/year):

• Start with a second-generation oral antihistamine (cetirizine, fexofenadine, desloratadine, or loratadine) OR an intranasal antihistamine (azelastine or olopatadine) 2
• These agents effectively control sneezing, itching, and rhinorrhea 1, 2

Moderate to severe or persistent symptoms (> 4 days/week and > 4 weeks/year):

• Initiate intranasal corticosteroid monotherapy (fluticasone, mometasone, budesonide, or triamcinolone) as first-line treatment 1, 2
• Intranasal corticosteroids relieve all nasal symptoms including congestion, itching, rhinorrhea, and sneezing, and prevent late-phase allergic responses almost completely 3, 4
• Administer once daily with proper technique: direct spray away from the nasal septum toward the lateral nasal wall to minimize epistaxis and septal perforation risk 1, 5

If intranasal corticosteroid monotherapy is inadequate after 2-4 weeks:

• Add an intranasal antihistamine (azelastine) to the intranasal corticosteroid regimen 5
• This combination provides superior symptom reduction (37.9% improvement) compared to intranasal corticosteroid alone (29.1% improvement) 5

For Nonallergic Rhinitis

The treatment differs significantly from allergic rhinitis:

• Intranasal antihistamines (azelastine or olopatadine) are first-line therapy, either as monotherapy or combined with intranasal corticosteroids 1, 2
• Intranasal corticosteroids may relieve congestion and rhinorrhea in vasomotor rhinitis 1
• Oral nonsedating antihistamines are NOT effective in nonallergic rhinitis and should not be prescribed 1
• For predominant rhinorrhea (gustatory rhinitis), intranasal anticholinergics (ipratropium bromide) are specifically indicated 1, 6

Adjunctive Therapies

Environmental Control Measures

• Implement allergen avoidance even during initial treatment 1
• For severe seasonal allergic rhinitis, advise staying indoors in air-conditioned environments with closed windows and doors 1

Decongestants (Use With Extreme Caution)

Topical decongestants (oxymetazoline, xylometazoline):

• Limit use to maximum 3 days only to prevent rhinitis medicamentosa (rebound congestion) 1, 5
• May be used short-term to reduce severe congestion and allow intranasal corticosteroids to penetrate nasal mucosa effectively 5
• Development of rhinitis medicamentosa is highly variable—can occur within 3 days or fail to develop after 6 weeks 1

Oral decongestants (pseudoephedrine):

• Effective for nasal congestion but cause insomnia, irritability, palpitations, and appetite loss 1
• Use with caution in patients with cardiovascular disease, hyperthyroidism, closed-angle glaucoma, or bladder neck obstruction 1
• Monitor blood pressure in all patients, especially those with controlled hypertension 1
• Avoid in children under 6 years of age due to risk of agitated psychosis, ataxia, hallucinations, and death 1
• Phenylephrine is less effective than pseudoephedrine and has not been well-established as an oral decongestant 1

Nasal Saline Irrigation

• Use 2-3 times daily as cornerstone therapy for rhinitis sicca (dry nasal mucosa) 7
• Provides mechanical moisturization and crust removal 7

Critical Pitfalls to Avoid

Medications that worsen specific rhinitis subtypes:

• Never use topical decongestants beyond 3 days—rhinitis medicamentosa will worsen underlying congestion 1, 7, 5
• Avoid topical decongestants entirely in rhinitis sicca—they further dry nasal mucosa 7
• Do not prescribe oral antihistamines for rhinitis sicca or nonallergic rhinitis—anticholinergic effects worsen dryness and they lack efficacy in nonallergic rhinitis 1, 7
• Avoid prolonged intranasal corticosteroid use without adequate moisturization in rhinitis sicca—can exacerbate dryness 7

Proper intranasal corticosteroid use:

• Ensure daily administration at regular intervals, not as-needed, for optimal effect 5
• Monitor nasal septum periodically for mucosal erosions when using intranasal corticosteroids, especially in rhinitis sicca 7
• Use lowest effective dose if inflammation requires treatment in dry nasal conditions 7

Special considerations for rhinitis medicamentosa:

• Discontinue nasal decongestant sprays and treat with intranasal or systemic corticosteroids 1

Assessment of Treatment Response

Evaluate multiple parameters at follow-up 1:

• Nasal symptoms (congestion, itching, rhinorrhea)
• Physical signs (turbinate edema)
• Quality of life (sleep quality, work/school performance, driving ability)
• Comorbid conditions (asthma control often improves with rhinitis control) 1

Indications for Allergist/Immunologist Referral

Refer when any of the following occur 1:

• Prolonged manifestations despite treatment
• Complications (otitis media, sinusitis, nasal polyposis)
• Comorbid asthma or chronic sinusitis
• Requirement for systemic corticosteroids
• Symptoms or medication side effects interfering with function or sleep
• Significant quality of life impairment (anosmia, ageusia)
• Treatment ineffectiveness or adverse events
• Rhinitis medicamentosa diagnosis
• Need for allergen identification or immunotherapy consideration
• Multiple costly medications required over prolonged periods 1

Special Populations

Pediatric patients:

• OTC cough and cold medications (antihistamine-decongestant combinations) are not effective in children and have safety concerns 1
• Oral decongestants in children under 6 years carry significant risks including tachyarrhythmias, insomnia, hyperactivity, and even death at recommended doses 1

Infectious rhinitis:

• Treat with supportive measures to relieve ostiomeatal obstruction 1
• Use judicious antibiotics only for suspected bacterial sinusitis 1