Steroid Nasal Sprays and Epistaxis Risk
All intranasal corticosteroids can cause epistaxis (nosebleeds), but proper administration technique reduces this risk by four-fold, and the bleeding is typically mild (blood-tinged secretions rather than frank bleeding). 1
Understanding the Epistaxis Risk
Epistaxis occurs with all intranasal corticosteroids as a class effect, typically presenting as blood-tinged nasal secretions rather than severe nosebleeds. 1
The incidence increases with higher doses—high-dose regimens (e.g., mometasone 400 µg vs 200 µg) double the risk of epistaxis (RR 2.06,95% CI 1.20-3.54), though most cases are mild and rarely require discontinuation. 2
No specific intranasal corticosteroid molecule has been proven superior in preventing epistaxis—studies comparing fluticasone propionate, mometasone furoate, beclomethasone dipropionate, and budesonide show similar rates of nasal bleeding across agents. 2, 3
Critical Technique to Minimize Bleeding
The contralateral hand technique reduces epistaxis risk by 4-fold compared to ipsilateral spraying. 4, 5
Direct the spray away from the nasal septum by using the opposite hand for each nostril (right hand for left nostril, left hand for right nostril). 1
Keep the head upright during administration and breathe in gently—avoid forceful inhalation. 4, 5
Do not close the opposite nostril during spraying, as this increases pressure and trauma risk. 4, 5
Periodically examine the nasal septum (every 6-12 months during long-term use) to detect mucosal erosions that may precede septal perforation, a rare but serious complication. 1
Choosing the Optimal Agent and Dose
Start with standard-dose mometasone furoate 200 µg once daily or fluticasone propionate 100 µg once daily (2 sprays per nostril), as these provide excellent efficacy with the lowest epistaxis risk. 4, 6, 3
Avoid high-dose regimens unless absolutely necessary for severe symptoms unresponsive to standard dosing, as doubling the dose doubles the bleeding risk without proportional symptom benefit. 2
Mometasone furoate and fluticasone propionate have negligible systemic bioavailability, making them preferred for long-term safety. 7
Once-daily dosing improves adherence and may reduce cumulative nasal trauma compared to twice-daily regimens. 7, 6
Alternative Formulations
Aqueous nasal sprays are standard—there is insufficient evidence that aerosol formulations differ in epistaxis rates. 1, 2
Avoid propylene glycol-containing solutions if burning/stinging is problematic, as this excipient causes more local irritation. 1
Benzalkonium chloride preservatives may impair mucociliary function, though clinical significance for epistaxis is unclear. 1
When Epistaxis Becomes Problematic
Severe or frequent nosebleeds require stopping the medication and medical evaluation to rule out nasal septal damage. 8
A constant whistling sound may indicate septal perforation—discontinue immediately and seek urgent evaluation. 8
Blood-tinged mucus or occasional streaks of blood are common and generally tolerable; patients can continue treatment if symptoms are controlled and bleeding is minimal. 1
Important Caveats
No intranasal corticosteroid is completely free of epistaxis risk—the goal is minimization through proper technique and appropriate dosing. 1, 2
Patients with history of frequent/severe epistaxis should receive explicit instruction on contralateral technique before starting therapy. 4, 5
Nasal saline irrigation performed before steroid application may reduce mucosal irritation, though evidence is limited. 4
Do not use topical decongestants concurrently for more than 3 days, as rebound congestion will worsen the underlying condition. 4