Treatment of Runny, Itchy Nose with Nasal Congestion
Start with an intranasal corticosteroid (fluticasone, mometasone, budesonide, or triamcinolone) as first-line monotherapy—this is the single most effective treatment for controlling all symptoms including nasal congestion, rhinorrhea, sneezing, and itching. 1, 2
First-Line Treatment Algorithm
Initiate intranasal corticosteroid immediately at the standard adult dose (typically 2 sprays per nostril once daily) without requiring a prior trial of antihistamines or decongestants. 1, 2 This recommendation is based on strong evidence from the American Academy of Allergy, Asthma, and Immunology and American Academy of Otolaryngology-Head and Neck Surgery showing intranasal corticosteroids are superior to all other medication classes for comprehensive symptom control. 1, 3
Why Intranasal Corticosteroids First?
- Addresses all three symptoms simultaneously: Unlike oral antihistamines that have minimal effect on congestion, intranasal corticosteroids effectively treat nasal congestion, rhinorrhea, and itching. 1, 4, 5
- Broad anti-inflammatory mechanism: They block multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes) rather than just histamine alone. 6, 7
- Most potent long-term option: Intranasal corticosteroids are the most effective pharmacologic treatment for nasal congestion associated with both allergic and nonallergic rhinitis. 4, 7
Critical Administration Instructions
Direct the spray away from the nasal septum toward the lateral nasal wall to maximize mucosal contact, improve drug delivery, and prevent local complications like mucosal erosions or septal perforation. 1, 2
Use daily at regular intervals, not as-needed, because it may take several days to reach maximum effect. 6 Continue daily use as long as exposed to triggering allergens or irritants. 6
If Severe Congestion Prevents Medication Delivery
For patients with severe nasal obstruction that may prevent the intranasal corticosteroid from reaching the nasal mucosa:
- Add topical oxymetazoline for a maximum of 3 days only to open the nasal passages. 1, 8
- Critical warning: Never exceed 3 days of topical decongestant use to avoid rhinitis medicamentosa (rebound congestion), which will worsen the underlying problem. 1, 2, 8
Escalation for Inadequate Response After 2-4 Weeks
If symptoms persist despite daily intranasal corticosteroid use for 2-4 weeks, add an intranasal antihistamine (azelastine or olopatadine) to the regimen. 1, 2, 8
- This combination provides superior symptom reduction compared to either agent alone (37.9% vs 29.1% symptom score reduction). 1, 8
- The combination is specifically recommended by the American Academy of Otolaryngology-Head and Neck Surgery for moderate-to-severe symptoms. 1, 2
- Do not add oral antihistamines to intranasal corticosteroids—multiple high-quality trials show no additional benefit. 1, 2
Additional Adjunctive Measures
Nasal Saline Irrigation
Use nasal saline irrigation (isotonic or hypertonic) as adjunctive therapy to help clear secretions, allergens, and inflammatory mediators. 9, 1, 2 This can be used as sole therapy for mild symptoms or combined with pharmacotherapy. 9, 1
Environmental Control
Implement allergen avoidance measures early, even before confirming specific triggers:
- Keep windows closed and use air conditioning during high pollen periods. 1, 2
- Use HEPA air filtration in bedrooms. 1
- Shower and change clothing after outdoor exposure. 1
What NOT to Do: Common Pitfalls
| Pitfall | Why to Avoid | Citation |
|---|---|---|
| Starting with oral antihistamines alone | Minimal effect on nasal congestion; less effective than intranasal corticosteroids for comprehensive symptom control | [1,4,5] |
| Using topical decongestants >3 days | Causes rhinitis medicamentosa (rebound congestion) requiring continued use even without allergen exposure | [1,2,5] |
| Adding oral antihistamines to intranasal corticosteroids | No additional benefit demonstrated in multiple trials | [1,2] |
| Using leukotriene receptor antagonants as primary therapy | Less effective than intranasal corticosteroids; should not be first-line | [1,2] |
| Intermittent "as-needed" use of intranasal corticosteroids | Requires daily use for several days to reach maximum effect | [6] |
When to Refer or Consider Immunotherapy
Refer to an allergist/immunologist if:
- Symptoms remain inadequately controlled after 4-8 weeks of optimal pharmacotherapy (intranasal corticosteroid + intranasal antihistamine). 1, 2
- Quality of life remains significantly impaired despite treatment. 1, 2
- Patient desires disease-modifying treatment rather than daily medication. 1, 2
Allergen immunotherapy (subcutaneous or sublingual) is the only treatment that modifies the natural history of allergic rhinitis and may prevent development of asthma and new allergen sensitizations. 1, 2, 7
Special Populations
Children Age 4-11
- Use lower dose: 1 spray per nostril once daily (vs. 2 sprays for adults ≥12 years). 6
- Limit to 2 months per year before checking with a doctor due to potential growth rate effects. 6