Medical Care

Once rhinitis medicamentosa is identified, topical decongestant use must be discouraged and discontinued as soon as possible. Patients need to be educated on their condition and offered other methods of treatment that will help them with the medical conditions that originally triggered the intranasal decongestant use. For allergic rhinitis, for example, this might include allergen reduction/avoidance, pharmacotherapy, and/or allergen immunotherapy. For those patients unable or unwilling to immediately stop intranasal decongestants, several strategies may ease the withdrawal process.

The first week is often the most difficult for weaning or withdrawal. Several studies confirm efficacy of nasal corticosteroids in the treatment and prevention of rhinitis medicamentosa. Although not always necessary, short-course oral corticosteroids, as described below, are the most effective way to break the cyclic use of topical vasoconstrictors. The oral corticosteroids are often used for 5-10 days, with nasal corticosteroids started at the same time and continued until the process is corrected.

Nasal irrigation with saline solutions delivered by devices such as NeilMed may be useful.

Intranasal decongestants can be weaned gradually, allowing patients to use sprays at night in one nostril only and alternating the left and right nostril until congestion is decreased.

Pain relief from analgesics should be offered to patients who experience headaches during withdrawal from intranasal decongestants.

Oral systemic decongestants may be helpful in relieving nasal congestion as intranasal decongestants are withdrawn.

Pregnancy

Rhinitis of pregnancy affects as many as 20% of expecting mothers, although the most common causes of nasal symptoms in pregnant women are the same as in men and nonpregnant women.

Therapy for a pregnant patient with rhinitis medicamentosa generally is the same as outlined above, although oral decongestants should be avoided in the first trimester because of risk of gastroschisis.^[2]

Continuous positive airway pressure (CPAP)-induced rhinitis

CPAP prescribed for sleep apnea, can cause increased air flow through the nasal cavity, which, in turn, causes dry mucous membrane, overproduction of the mucus, and congestion.

Appropriate use of such machines should be ensured, including evaluation of pressure used, regular maintenance, and humidification of the air delivered. Nasal gel is recommended to prevent drying of the mucous membranes of the nasal cavity.

Surgical Care

Surgical treatment generally is not recommended unless polyps or significantly deviated nasal septum are present and causing nasal congestion. However, when inferior turbinate hypertrophy is present with nasal obstruction and patients have failed medical management, partial inferior turbinate reduction is an option.^[22]

Consultations

Consult an allergist, immunologist, or otorhinolaryngologist if a patient's case is complicated and refractory to treatment or if the primary care physician is unsure of diagnosis.

Follow-up

Black MJ, Remsen KA. Rhinitis medicamentosa. Can Med Assoc J. 1980 Apr 19. 122(8):881-4. [QxMD MEDLINE Link].
[Guideline] Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008 Aug. 122(2 Suppl):S1-84. [QxMD MEDLINE Link]. [Full Text].
Doshi J. Rhinitis medicamentosa: what an otolaryngologist needs to know. Eur Arch Otorhinolaryngol. 2009 May. 266(5):623-5. [QxMD MEDLINE Link].
Ramey JT, Bailen E, Lockey RF. Rhinitis medicamentosa. J Investig Allergol Clin Immunol. 2006. 16(3):148-55. [QxMD MEDLINE Link].
Graf P. Rhinitis medicamentosa: a review of causes and treatment. Treat Respir Med. 2005. 4(1):21-9. [QxMD MEDLINE Link].
Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy. 1997. 52(40 Suppl):28-34. [QxMD MEDLINE Link].
Graf P, Hallen H, Juto JE. The pathophysiology and treatment of rhinitis medicamentosa. Clin Otolaryngol. 1995 Jun. 20(3):224-9. [QxMD MEDLINE Link].
Morissette G, Bouthillier J, Marceau F. Trapping of adrenergic decongestant drugs into cellular endomembrane compartments: toxicological and pharmacological consequences. Int Immunopharmacol. 2007 Dec 20. 7(14):1869-79. [QxMD MEDLINE Link].
Baroody FM, Brown D, Gavanescu L, DeTineo M, Naclerio RM. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol. 2011 Apr. 127(4):927-34. [QxMD MEDLINE Link].
Marple B, Roland P, Benninger M. Safety review of benzalkonium chloride used as a preservative in intranasalsolutions: an overview of conflicting data and opinions. Otolaryngol Head Neck Surg. 2004 Jan. 130(1):131-41. [QxMD MEDLINE Link].
Bernstein IL. Is the use of benzalkonium chloride as a preservative for nasal formulations a safety concern? A cautionary note based on compromised mucociliary transport. J Allergy Clin Immunol. 2000 Jan. 105(1 Pt 1):39-44. [QxMD MEDLINE Link].
Graf P. Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa. Clin Ther. 1999 Oct. 21(10):1749-55. [QxMD MEDLINE Link].
Graf P. Benzalkonium chloride as a preservative in nasal solutions: re-examining the data. Respir Med. 2001 Sep. 95(9):728-33. [QxMD MEDLINE Link].
Graf P, Hallen H. Effect on the nasal mucosa of long-term treatment with oxymetazoline, benzalkonium chloride, and placebo nasal sprays. Laryngoscope. 1996 May. 106(5 Pt 1):605-9. [QxMD MEDLINE Link].
Graf P, Hallen H, Juto JE. Benzalkonium chloride in a decongestant nasal spray aggravates rhinitis medicamentosa in healthy volunteers. Clin Exp Allergy. 1995 May. 25(5):395-400. [QxMD MEDLINE Link].
Toohill RJ, Lehman RH, Grossman TW, Belson TP. Rhinitis medicamentosa. Laryngoscope. 1981 Oct. 91(10):1614-21. [QxMD MEDLINE Link].
Osguthorpe JD, Shirley R. Neonatal respiratory distress from rhinitis medicamentosa. Laryngoscope. 1987 Jul. 97(7 Pt 1):829-31. [QxMD MEDLINE Link].
Graf PM, Hallen H. One year follow-up of patients with rhinitis medicamentosa after vasoconstrictor withdrawal. Am J Rhinol. 1997 Jan-Feb. 11(1):67-72. [QxMD MEDLINE Link].
Graf P, Hallen H. One-week use of oxymetazoline nasal spray in patients with rhinitis medicamentosa 1 year after treatment. ORL J Otorhinolaryngol Relat Spec. 1997 Jan-Feb. 59(1):39-44. [QxMD MEDLINE Link].
Mabry RL. Rhinitis medicamentosa: the forgotten factor in nasal obstruction. South Med J. 1982 Jul. 75(7):817-9. [QxMD MEDLINE Link].
Lekas MD. Rhinitis during pregnancy and rhinitis medicamentosa. Otolaryngol Head Neck Surg. 1992 Dec. 107(6 Pt 2):845-8; discussion 849. [QxMD MEDLINE Link].
Seidman MD, Gurgel RK, Lin SY, Schwartz SR, Baroody FM, Bonner JR, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015 Feb. 152 (2):197-206. [QxMD MEDLINE Link].
Baroody FM, Brown D, Gavanescu L, DeTineo M, Naclerio RM. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol. 2011 Apr. 127 (4):927-34. [QxMD MEDLINE Link].
Meltzer EO, Bernstein DI, Prenner BM, Berger WE, Shekar T, Teper AA. Mometasone furoate nasal spray plus oxymetazoline nasal spray: short-term efficacy and safety in seasonal allergic rhinitis. Am J Rhinol Allergy. 2013 Mar-Apr. 27 (2):102-8. [QxMD MEDLINE Link].
Vaidyanathan S, Williamson P, Clearie K, Khan F, Lipworth B. Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion. Am J Respir Crit Care Med. 2010 Jul 1. 182 (1):19-24. [QxMD MEDLINE Link].
Talaat M, Belal A, Aziz T, et al. Rhinitis medicamentosa: electron microscopic study. J Laryngol Otol. 1981 Feb. 95(2):125-31. [QxMD MEDLINE Link].
Lin CY, Cheng PH, Fang SY. Mucosal changes in rhinitis medicamentosa. Ann Otol Rhinol Laryngol. 2004 Feb. 113(2):147-51. [QxMD MEDLINE Link].
Baldwin RL. Rhinitis medicamentosa (an approach to treatment). J Med Assoc State Ala. 1975 Aug. 47(2):33-5. [QxMD MEDLINE Link].
Behrman RE, Kliegman RM, Jenson HB. Allergic Disorders. In: Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa:. WB Saunders. 2000:653-663.
Caffier PP, Frieler K, Scherer H, Sedlmaier B, Göktas O. Rhinitis medicamentosa: therapeutic effect of diode laser inferior turbinate reduction on nasal obstruction and decongestant abuse. Am J Rhinol. 2008 Jul-Aug. 22(4):433-9. [QxMD MEDLINE Link].
Elwany SS, Stephanos WM. Rhinitis medicamentosa. An experimental histopathological and histochemical study. ORL J Otorhinolaryngol Relat Spec. 1983. 45(4):187-94. [QxMD MEDLINE Link].
Fleece L, Mizes JS, Jolly PA, Baldwin RL. Rhinitis medicamentosa. Conceptualization, incidence, and treatment. Ala J Med Sci. 1984 Apr. DA - 19840716(2):205-8. [QxMD MEDLINE Link].
Graf P. Long-term use of oxy- and xylometazoline nasal sprays induces rebound swelling, tolerance, and nasal hyperreactivity. Rhinology. 1996 Mar. 34(1):9-13. [QxMD MEDLINE Link].
Graf PM, Hallen H. Changes in nasal reactivity in patients with rhinitis medicamentosa after treatment with fluticasone propionate and placebo nasal spray. ORL J Otorhinolaryngol Relat Spec. 1998 Nov-Dec. 60(6):334-8. [QxMD MEDLINE Link].
Kully B. The use and abuse of nasal vasoconstrictor medication. JAMA. 1945. 127:307-310.
Lasley MK. Rhinitis and sinusitis in children. 1999. 19:437-448.
Scadding GK. Rhinitis medicamentosa [editorial]. Clin Exp Allergy. 1995 May. 25(5):391-4. [QxMD MEDLINE Link].
Wang JQ, Bu GX. Studies of rhinitis medicamentosa. Chin Med J (Engl). 1991 Jan. 104(1):60-3. [QxMD MEDLINE Link].
Yoo JK, Seikaly H, Calhoun KH. Extended use of topical nasal decongestants. Laryngoscope. 1997 Jan. 107(1):40-3. [QxMD MEDLINE Link].

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Author

Mark S Dykewicz, MD Raymond and Alberta Slavin Endowed Professor in Allergy and Immunology, Professor of Internal Medicine, Chief, Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Director, Allergy and Immunology Fellowship Program, St Louis University School of Medicine

Mark S Dykewicz, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Thoracic Society, Clinical Immunology Society, European Academy of Allergy and Clinical Immunology

Disclosure: Received income in an amount equal to or greater than $250 from: Pharming.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John E McClay, MD Associate Professor of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Children's Hospital of Dallas, University of Texas Southwestern Medical Center

John E McClay, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; Medical Director, Institute for Asthma and Allergy

Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, Association of American Physicians

Disclosure: Nothing to disclose.

Additional Contributors

William F Schoenwetter, MD Consultant in Allergic Diseases, Brainerd Medical Center, Brainerd, Minnesota

William F Schoenwetter, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Medical Association, Joint Council of Allergy, Asthma and Immunology, Minnesota Medical Association

Disclosure: Nothing to disclose.

Natalya M Kushnir, MD, FAAAAI Director, Allergy and Immunology Clinic of the East Bay; Clinical Co-Director, Breathmobile Clinic of Northern California

Natalya M Kushnir, MD, FAAAAI is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Received honoraria from MEDA for speaking and teaching; Received honoraria from GSK for speaking and teaching; Received honoraria from MERCK-Sherring for speaking and teaching; Received honoraria from Alcon for speaking and teaching.