What is the best treatment for a patient with a runny nose, considering potential underlying conditions such as allergies or bacterial infection?

Treatment of Runny Nose

For allergic rhinitis with runny nose, intranasal corticosteroids are the most effective first-line treatment, while for viral upper respiratory infections (common cold), supportive care with saline irrigation is recommended—antibiotics have no role unless bacterial sinusitis develops with specific criteria. 1

Determine the Underlying Cause

The treatment approach depends critically on identifying whether the runny nose stems from:

• Allergic rhinitis: Clear rhinorrhea with sneezing, itchy nose, nasal congestion, pale nasal mucosa, and red/watery eyes 1
• Viral URI (common cold): Self-limited illness with rhinorrhea, sneezing, sore throat, cough, low-grade fever, and malaise 1
• Acute bacterial rhinosinusitis (ABRS): Symptoms persisting >10 days without improvement, severe symptoms (fever >39°C, purulent discharge, facial pain) for ≥3 consecutive days, or worsening after initial improvement ("double sickening") 1

For Allergic Rhinitis (Most Common Cause)

First-Line Monotherapy

Intranasal corticosteroids (fluticasone, mometasone, budesonide) should be recommended as primary therapy for patients whose symptoms affect quality of life. 1 These are the most effective medication class for controlling all major symptoms including rhinorrhea, with onset within 12 hours and continued improvement over weeks. 2

• Dose: 2 sprays per nostril once daily for adults 3
• Critical technique: Direct spray laterally away from the nasal septum to minimize bleeding risk 2

Alternative or Adjunct Options

• Oral second-generation antihistamines (cetirizine, loratadine) are strongly recommended for patients with primary complaints of sneezing, itching, and runny nose 1, 4, 5

  • These are less effective than intranasal steroids for overall symptom control but work well for rhinorrhea and sneezing 1
  • Avoid first-generation antihistamines due to sedation and anticholinergic effects 2

• Intranasal antihistamines may be offered as an option, particularly when combined with intranasal corticosteroids for inadequate relief 1, 2

• Saline nasal irrigation can be used as adjunctive therapy to clear mucus and allergens 1, 6, 7

  • Isotonic or hypertonic (2-3.5%) solutions are both effective 7, 8
  • Can be performed 10-20 minutes before intranasal corticosteroid to increase efficacy 6

What NOT to Do

• Do not offer oral leukotriene receptor antagonists as primary therapy—they are less effective than intranasal corticosteroids 1, 2
• Avoid topical decongestants (oxymetazoline, xylometazoline) for more than 3 consecutive days due to risk of rebound congestion (rhinitis medicamentosa) 1, 3, 9

For Viral Upper Respiratory Infection (Common Cold)

Most patients should be managed with supportive care only; antibiotics provide no benefit and cause more harm than good. 1

Recommended Supportive Measures

• Saline nasal irrigation to clear mucus and improve symptoms 1, 6, 10
• Analgesics for pain and antipyretics for fever 1
• Systemic or topical decongestants for short-term use (≤3 days) 1, 9
• Antihistamines have no role in symptomatic relief for nonatopic patients with viral infections 1

Critical Pitfall to Avoid

Antibiotics should NOT be prescribed for common cold—they do not prevent complications (sinusitis, otitis media, asthma exacerbation) and increase adverse effects and resistance. 1

For Acute Bacterial Rhinosinusitis (ABRS)

When to Consider Antibiotics

Only prescribe antibiotics when patients meet specific criteria 1:

• Symptoms persisting >10 days without improvement
• Severe symptoms: fever >39°C, purulent nasal discharge, or facial pain for ≥3 consecutive days
• Worsening symptoms after initial improvement ("double sickening")

Treatment Options

Watchful waiting (without antibiotics) should be offered as initial management for uncomplicated ABRS when follow-up is assured. 1 Many patients improve spontaneously, and antibiotics can be started if symptoms fail to improve by 7 days or worsen at any time. 1

If antibiotics are prescribed:

• Amoxicillin-clavulanate is the preferred agent per IDSA guidelines 1
• Alternative: Doxycycline or respiratory fluoroquinolone 1
• Some societies recommend amoxicillin as preferred agent 1

Adjunctive Therapy

• Intranasal saline irrigation or intranasal corticosteroids have been shown to alleviate symptoms and potentially decrease antibiotic use 1
• Topical decongestants may be used for ≤3-5 days 1

Important Caveat

The number needed to treat with antibiotics for ABRS is 18 for one patient to be cured rapidly, but the number needed to harm from adverse effects is only 8. 1 This underscores the importance of selective antibiotic use.

For Nonallergic Rhinitis (Vasomotor Rhinitis)

• Intranasal corticosteroids are primary treatment 1
• Anticholinergics (ipratropium) to relieve rhinorrhea 1
• Avoid aggravating irritants 1
• Antihistamines have no role unless allergic component is present 1