Management of Scratchy Throat Due to Viral Infection
For a scratchy throat caused by a viral upper respiratory infection, use acetaminophen or ibuprofen for symptom relief, avoid antibiotics entirely, and reassure the patient that symptoms will resolve within 7–10 days. 1
Confirm the Diagnosis is Viral
- The vast majority (98–99.5%) of acute upper respiratory infections are viral and resolve spontaneously within 7–10 days without antibiotics. 1
- Viral symptoms typically include scratchy throat, nasal congestion, clear rhinorrhea, cough, sneezing, and low-grade fever that peak within 3 days. 2
- Do not prescribe antibiotics for viral upper respiratory infections—they provide no benefit, increase adverse effects (number needed to harm = 8), and drive antimicrobial resistance. 1, 2
First-Line Symptomatic Treatment
- Acetaminophen 1000 mg every 4–6 hours (maximum 4000 mg/24 hours) is the preferred first-line agent for throat pain and fever due to its superior safety profile—no gastrointestinal bleeding, renal toxicity, or cardiovascular risk. 1
- Ibuprofen 400–600 mg every 6–8 hours is an alternative analgesic for pain and fever control. 1, 2
- Saline nasal irrigation 2–3 times daily provides modest symptom relief by facilitating clearance of nasal secretions. 1
Additional Symptomatic Options
- Oral antihistamines (e.g., pheniramine 25–50 mg three times daily) may reduce excessive secretions and sneezing, though evidence is limited; first-generation agents cause sedation and anticholinergic effects, so use cautiously in elderly patients. 2
- Oral decongestants (e.g., pseudoephedrine) can relieve nasal congestion if not contraindicated by hypertension or anxiety. 2
- Topical nasal decongestants (e.g., oxymetazoline) may be used for severe congestion but limit to ≤3 days to avoid rebound rhinitis medicamentosa. 1, 2
- Warm saline gargles and throat lozenges (including those with amylmetacresol/dichlorobenzyl alcohol or hexylresorcinol) provide local symptomatic relief and may have virucidal effects in vitro. 2, 3
Patient Education and Safety Netting
- Symptoms typically last up to 2 weeks and are self-limited; the illness resolves without antibiotics even when bacterial pathogens are present. 1
- Hand hygiene is the most effective method to reduce transmission. 1
- Return precautions: Instruct the patient to seek care if symptoms persist ≥10 days without improvement, fever ≥39°C with purulent nasal discharge for ≥3 consecutive days, or worsening after initial improvement ("double sickening")—these patterns suggest bacterial sinusitis requiring antibiotics. 1, 2
- Other red flags include severe headache, visual changes, periorbital swelling, neck stiffness, respiratory distress, or altered mental status. 2
What NOT to Do
- Do not prescribe antibiotics for viral upper respiratory infections—they are ineffective, do not prevent complications (bacterial sinusitis, otitis media, asthma exacerbation), and significantly increase adverse effects. 1
- Do not use intranasal corticosteroids for common cold symptomatic relief—there is no evidence of benefit. 1
- Vitamin C and echinacea have no proven benefit. 1
- Do not base treatment decisions on purulent nasal discharge alone—this is a normal feature of viral colds reflecting neutrophil presence, not bacterial infection. 4, 1