Oral Corticosteroids for Eye-Watering from Allergic Rhinitis
No, you should not use oral corticosteroids to treat eye-watering caused by allergic rhinitis—intranasal corticosteroids are the most effective first-line treatment and should be used instead. 1
Why Oral Corticosteroids Are Not Appropriate
Oral corticosteroids should not be administered as therapy for chronic rhinitis, except for rare patients with severe intractable nasal symptoms who are unresponsive to other modalities of treatment. 1
A short course (5-7 days) of oral corticosteroids may be appropriate only for very severe or intractable nasal symptoms or significant nasal polyposis—not for routine allergic rhinitis symptoms like eye-watering. 1
Parenteral (injectable) corticosteroid administration is not recommended and recurrent parenteral corticosteroid administration is contraindicated because of greater potential for long-term side effects including prolonged adrenal suppression, local muscle atrophy, and fat necrosis. 1
The Correct Treatment: Intranasal Corticosteroids
Intranasal corticosteroids are the most effective medications for treating allergic rhinitis and its associated symptoms, including eye-watering. 1, 2
Why Intranasal Steroids Work for Eye Symptoms
Intranasal corticosteroids may benefit ocular allergy symptoms associated with allergic rhinitis, as they address the underlying allergic inflammation affecting the entire upper airway. 1, 3
In systematic reviews, intranasal corticosteroids were not significantly different from antihistamines for relief of eye symptoms, meaning they provide adequate control of eye-watering without systemic steroid exposure. 1
Specific Intranasal Steroid Options
First-line choices include fluticasone propionate (2 sprays per nostril once daily for adults), mometasone furoate (2 sprays per nostril once daily for adults ≥12 years), or triamcinolone acetonide. 2
The onset of therapeutic effect occurs within 12 hours and as early as 3-4 hours in some patients, with maximal efficacy reached in days to weeks of regular use. 1, 2
All available intranasal corticosteroids have similar overall clinical response regardless of differences in topical potency, lipid solubility, and binding affinity. 1
Safety Profile of Intranasal Steroids
Intranasal corticosteroids at recommended doses are not associated with clinically significant systemic side effects—no consistent effect on hypothalamic-pituitary-adrenal axis, ocular pressure, cataract formation, or bone density. 1
Studies with fluticasone propionate, mometasone furoate, and budesonide show no effect on growth in children at recommended doses compared to placebo. 1, 2
Local side effects such as nasal irritation, bleeding, and nasal septal perforation are rare and can be avoided with proper administration technique (directing spray away from septum). 1, 2
Alternative Treatments for Eye Symptoms
If eye-watering persists despite intranasal corticosteroids:
Add an oral second-generation antihistamine (such as cetirizine, loratadine, or fexofenadine) for additional relief of ocular symptoms. 1, 4
Consider topical ophthalmic agents such as dual-action agents (olopatadine, ketotifen) that possess both antihistamine and mast cell stabilizer activities with onset within 30 minutes. 1
Oral antihistamines are generally less effective in relieving ocular allergy symptoms than topical ophthalmic agents and have slower onset of action. 1
Direct Comparison: Intranasal vs. Oral Corticosteroids
A direct comparison study found that intranasal mometasone furoate and oral betamethasone have virtually equivalent effects on nasal symptoms in seasonal allergic rhinitis. 5
Treatment with intranasal corticosteroid spray is more strongly recommended than systemic corticosteroids due to the side effects associated with oral steroids. 5
Topical corticosteroids sufficiently improve symptoms without the systemic risks of oral corticosteroids, including adrenal suppression, bone loss, glucose intolerance, and immunosuppression. 5
Common Pitfalls to Avoid
Do not prescribe oral corticosteroids for routine allergic rhinitis symptoms—reserve them only for very severe intractable cases unresponsive to all other treatments. 1
Do not assume intranasal steroids are less effective than oral steroids—they have equivalent efficacy with far superior safety profiles. 5
Ensure patients understand that intranasal corticosteroids require regular daily use for 2+ weeks to achieve full benefit, not as-needed use. 2
Direct the intranasal spray away from the nasal septum toward the lateral nasal wall to reduce epistaxis risk by 4-fold. 2, 3