For millions of people battling seasonal allergies or chronic nasal congestion, over-the-counter nasal sprays seem like a miracle cure—until they’re not. What begins as temporary relief can quickly spiral into a frustrating cycle of dependency and worsening symptoms, a condition known as rhinitis medicamentosa that also is called rebound nasal congestion or, more simply, rebound congestion.
Often overlooked or misunderstood, this condition arises when topical nasal decongestant sprays are used for more than just a few days, leading to swelling of the nasal passages and persistent stuffiness that can be even more severe than the original problem. Knowing more about proper nasal spray use and how to identify rhinitis medicamentosa is key.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
For this installment, John R. Craig, MD, an otolaryngologist and the rhinology division head at Henry Ford Health in Detroit, discusses what patients should know about rhinitis medicamentosa and nasal spray overuse.
Henry Ford Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Nasal sprays decrease congestion
“Some common causes of nasal obstruction would be allergic rhinitis or hay fever where the nasal passages become inflamed due to an allergic reaction to airborne allergens such as pollen, dust mites or pet dander,” said Dr. Craig, “and sinusitis, which is inflammation or swelling of the sinuses that can extend into and obstruct the nasal passages.”
“On top of that, patients can have different degrees of anatomic obstruction such as a deviated nasal septum or enlarged inferior turbinates. Inferior turbinates are bony structures lined by soft tissue, and either the soft tissue can swell up periodically throughout the day or when lying down, or the bones can be too large, and both situations can cause nasal airway obstruction,” he said.
“The different nasal sprays available often decrease the congestion in the nasal tissue lining and specifically the inferior turbinate tissue,” Dr. Craig added. “While different nasal sprays work in different manners, commonly used over the counter decongestion sprays bind to the receptors on blood vessels in the nasal tissue lining, constrict them, and that shrinks the puffy tissue—which makes you able to breathe through your nose better.”
Longer use leads to rebound congestion
When it comes to causes of rhinitis medicamentosa, it is the decongestant nasal sprays—such as oxymetazoline or phenylephrine—and not nasal steroids like Flonase or nasal antihistamines such as Astelin.
“The problem with some of these over-the-counter decongestion sprays is that when they wear off, the blood vessels enlarge again and sometimes larger than before, the nasal tissues get really puffy, and you get really stuffy,” Dr. Craig said. “That’s called rebound congestion.”
“Now, in patients who use these over-the-counter decongestion sprays for longer periods of time, there's this condition that's been termed rhinitis medicamentosa,” he said. “That implies they've developed nasal obstruction due to the spray.”
“The tough thing is it's not well established how frequently someone has to use these sprays to develop the condition, and there's also not great published data on long-term effects of using these sprays,” explained Dr. Craig. “The common teaching based on some studies is that it should be used for three days at a time to avoid this risk of rebound congestion.”
“However, there are other studies showing even patients using it up to a month or longer don't develop it,” he added, noting “we don't have the perfect answer to how long is too long to use nasal sprays—it varies with each patient.”
Only your nasal passages are affected
“The main or only symptom of this rhinitis medicamentosa is nasal congestion,” said Dr. Craig. “Whereas other types of rhinitis or sinusitis may cause other symptoms such as itchy eyes or nose, runny or snotty nose, or smell alterations.”
Rebound congestion is not a true addiction
With rhinitis medicamentosa, “a lot of patients are told that this is a significant problem or an addiction that they need to stop,” Dr. Craig said. “That creates a stigma or negative connotation with over-the-counter decongestion spray use.”
“A lot of information out there implies that this is some form of an addiction, but there’s very little evidence to support that,” he said. “It doesn’t mean it can’t be habit-forming in some patients, but a lot of patients are using these nasal sprays because they haven’t seen a doctor yet and they simply can’t breathe through their nose.”
Nasal sprays “are quite effective at alleviating nasal obstruction, but we need to be careful with the term addiction because we don’t have evidence to support it,” Dr. Craig said.
There’s no set criteria for diagnosis
“It has been reported that about 1% to 9% of patients present to allergists or otolaryngologists with this condition,” said Dr. Craig. “But it’s tough because we do not have established diagnostic criteria for the condition.
“And since many patients are managing their nasal obstruction without seeing doctors, presumably this is an underestimate of the condition’s prevalence,” he added.
It's better to start with a nasal corticosteroid
When it comes to nasal sprays, Dr. Craig recommends starting with an over-the-counter nasal corticosteroid such as fluticasone (Flonase) for treatment of nasal obstruction “because it’s longer-acting and unlikely to cause rebound congestion.”
“While it is theoretically possible to develop rebound congestion with nasal corticosteroid sprays, it’s much less likely,” he said, noting “it also works on multiple pathways. It’s going to decrease the inflammation behind the stuffy or congested tissue, and it might actually have some constriction effect on the blood vessels.”
“So, it’s hitting it from two angles as opposed to decongestant sprays like oxymetazoline. Such sprays don’t address the underlying inflammation,” Dr. Craig added. “In patients with possible rhinitis medicamentosa, they will usually be trialed on nasal and possibly nasal corticosteroids to try to wean them off the decongestant spray because some patients truly can get off the decongestant spray long-term and not need surgery.”
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Think twice about daily nasal spray use
“I developed rebound congestion in college,” said Dr. Craig. “I didn’t know about it, but I read about it online and realized that’s what I had.”
“If you’re using nasal spray and you’re getting stuffier after using it and you can’t stop using it, then you should be seeing an ear, nose and throat surgeon to discuss medical and surgical options,” he said.
Surgery may be an option
In a recently published study led by Dr. Craig, 86% of patients with rhinitis medicamentosa were able to stop using nasal sprays such as oxymetazoline after a safe outpatient surgery, and maintained stopping of the spray long-term. He believes surgery could be a better long-term fix than continued medical management or treating rebound congestion as a substance-use disorder.
There is also a paper out of Australia, and together, “both these studies show excellent results when you do appropriate nasal airway surgery in patients with rhinitis medicamentosa” he said.
Dr. Craig has firsthand experience with undergoing the nasal surgery to fix his nasal breathing. When he had the surgery, he experienced three days of discomfort but went back to work early on the fourth day, though most patients take a week off.
“Breathing freely through both sides of your nose without needing sprays one or more times a day is amazing, and having been a patient is probably one reason I advocate so strongly for appropriately indicated nasal airway surgery,” said Dr. Craig.
Use nasal sprays only as directed
To prevent or stop rebound nasal congestion, patients should only use nasal sprays as directed, said Dr. Craig. Patients should “read the package carefully if using over-the-counter nasal sprays to relieve their congestion.”
“If the nasal sprays do not reduce your congestion, though, contact your doctor,” he said. “Your doctor can recommend other congestion treatments that don’t lead to rhinitis medicamentosa.”
