RHINITIS MEDICAMENTOSA: PATHOPHYSIOLOGY, CLINICAL MANIFESTATIONS, AND CURRENT MANAGEMENTS STRATEGIES

Monika Kałwak; Patryk Dłubis; Sviatlana  Filitaryna; Monika Wiatr; Magda Marciniak; Cezary Orzechowski; Michał Gutowski; Wojciech Wojas; Justyna Żabicka; Kinga Lichtarska; Aleksandra Foryś

doi:10.31435/ijitss.3(51).2026.5791

Authors

Monika Kałwak Independent Public Healthcare Facility of the Ministry of Internal Affairs and Administration of Sergeant Grzegorz Załoga in Katowice, Poland https://orcid.org/0009-0000-4244-3086
Patryk Dłubis Municipal Hospital in Gliwice LLC, Gliwice, Poland https://orcid.org/0009-0009-2952-6675
Sviatlana Filitaryna Specialist Hospital of Dr. Tytus Chałubiński in Radom, Radom, Poland https://orcid.org/0009-0003-8897-0254
Monika Wiatr Specialist Hospital of Dr. Tytus Chałubiński in Radom, Radom, Poland https://orcid.org/0009-0000-2038-3174
Magda Marciniak Specialist Hospital of Dr. Tytus Chałubiński in Radom, Radom, Poland https://orcid.org/0009-0005-4016-6536
Cezary Orzechowski Medical University of Warsaw, Warsaw, Poland https://orcid.org/0009-0008-1265-311X
Michał Gutowski Medical University of Warsaw, Warsaw, Poland https://orcid.org/0009-0006-7865-8736
Wojciech Wojas Maria Skłodowska-Curie Warsaw Higher School, Warsaw, Poland https://orcid.org/0009-0007-4295-0599
Justyna Żabicka Maria Skłodowska-Curie Warsaw Higher School, Warsaw, Poland https://orcid.org/0009-0002-0612-0938
Kinga Lichtarska Lazarski University, Warsaw, Poland https://orcid.org/0009-0004-9319-8323
Aleksandra Foryś Provincial Specialist Hospital No. 5 of St. Barbara in Sosnowiec, Sosnowiec, Poland https://orcid.org/0009-0008-7983-1443

DOI:

https://doi.org/10.31435/ijitss.3(51).2026.5791

Keywords:

Rhinitis Medicamentosa, Nasal Decongestants, Rebound Congestion, Turbinate Hypertrophy, Intranasal Corticosteroids, Drug-Induced Rhinitis

Abstract

Background: Rhinitis medicamentosa (RM) is a non-allergic condition caused by the prolonged use of topical nasal decongestants. Despite its prevalence, it remains frequently underdiagnosed in clinical practice.

Objectives: This review synthesizes current knowledge on the pathophysiology, diagnostic criteria, and multifaceted treatment approaches for RM.

Methods: A comprehensive literature search was conducted across PubMed (up to 2026) focusing on alpha-adrenergic agonist-induced mucosal changes and therapeutic interventions.

Results: Chronic administration of sympathomimetics, such as xylometazoline, leads to adrenoceptor downregulation, secondary vasodilation, and permanent mucosal remodelling. Clinical presentation is characterized by rebound congestion and tachyphylaxis. Management centers on immediate or tapered decongestant cessation, supplemented by intranasal corticosteroids. In refractory cases involving turbinate hypertrophy, surgical intervention (e.g., conchoplasty) remains a definitive option.

Conclusions: RM represents a significant clinical challenge. Increasing clinical awareness and patient education regarding the risk of decongestant overuse are crucial for prevention and successful long-term outcomes.

References

Kaper, N. M., Aarts, M. C. J., van Benthem, P. P. G., et al. (2019). Otolaryngologists adhere to evidence-based guidelines for chronic rhinosinusitis. European Archives of Oto-Rhino-Laryngology, 276, 1101–1108. https://doi.org/10.1007/s00405-019-05289-9

Yang, X., Eremeeva, K., Svistushkin, V., et al. (2025). Variants of rhinitis medicamentosa treatment: A systematic review. European Archives of Oto-Rhino-Laryngology, 282, 4407–4416. https://doi.org/10.1007/s00405-025-09344-6

de la Hoz Caballer, B., Rodríguez, M., Fraj, J., Cerecedo, I., Antolín-Amérigo, D., & Colás, C. (2012). Allergic rhinitis and its impact on work productivity in primary care practice and a comparison with other common diseases: The cross-sectional study to evaluate work productivity in allergic rhinitis compared with other common diseases (CAPRI) study. American Journal of Rhinology & Allergy, 26(5), 390–394. https://doi.org/10.2500/ajra.2012.26.3799

Ramey, J. T., Bailen, E., & Lockey, R. F. (2006). Rhinitis medicamentosa. Journal of Investigational Allergology and Clinical Immunology, 16(3), 148–155.

Hellings, P. W., Klimek, L., Cingi, C., et al. (2017). Non-allergic rhinitis: Position paper of the European Academy of Allergy and Clinical Immunology. Allergy, 72, 1657–1665. https://doi.org/10.1111/all.13200

Lockey, R. F. (2006). Rhinitis medicamentosa and the stuffy nose. Journal of Allergy and Clinical Immunology, 118(5), 1017–1018. https://doi.org/10.1016/j.jaci.2006.06.018

Almutairi, A., Almutairi, H., Althwiny, F. A., Almutairi, A., Alwasil, S., Albadrani, N., Aljeri, Y., & Alawad, M. (2022). Awareness of the Unaizah populations in Al-Qassim Province in Saudi Arabia regarding nasal decongestant use for allergic rhinitis and their side effect. Journal of Family Medicine and Primary Care, 11(3), 1070–1076. https://doi.org/10.4103/jfmpc.jfmpc_1258_21

Wahid, N. W. B., & Shermetaro, C. (2023). Rhinitis medicamentosa. In StatPearls. StatPearls Publishing.

Patel, A., Levi, J. R., & Brook, C. D. (2020). Should excess topical decongestant use raise a red flag? Rhinitis medicamentosa and opioid use disorder. Annals of Otology, Rhinology & Laryngology, 129(2), 164–169. https://doi.org/10.1177/0003489419880576

Agnihotri, N. T., & McGrath, K. G. (2019). Allergic and nonallergic rhinitis. Allergy and Asthma Proceedings, 40(6), 376–379. https://doi.org/10.2500/aap.2019.40.4251

Hall, L. J., & Jackson, R. T. (1968). Effects of alpha and beta adrenergic agonists on nasal blood flow. Annals of Otology, Rhinology & Laryngology, 77(6), 1120–1130. https://doi.org/10.1177/000348946807700610

Malm, L. (1973). Stimulation of sympathetic nerve fibres to the nose in cats. Acta Oto-Laryngologica, 75(6), 519–526. https://doi.org/10.3109/00016487309139783

Eccles, R., & Wilson, H. (1974). The autonomic innervation of the nasal blood vessels of the cat. The Journal of Physiology, 238(3), 549–560. https://doi.org/10.1113/jphysiol.1974.sp010542

Proudman, R. G. W., & Baker, J. G. (2021). The selectivity of α-adrenoceptor agonists for the human α1A-, α1B-, and α1D-adrenoceptors. Pharmacology Research & Perspectives, 9(4), Article e00799. https://doi.org/10.1002/prp2.799

Proctor, D. F., & Adams, G. K., III. (1976). Physiology and pharmacology of nasal function and mucus secretion. Pharmacology & Therapeutics, Part B, 2(3), 493–509. https://doi.org/10.1016/0306-039X(76)90004-0

Richards, E., Lopez, M. J., & Maani, C. V. (2023). Phenylephrine. In StatPearls. StatPearls Publishing.

Graf, P. (2005). Rhinitis medicamentosa: A review of causes and treatment. Treatments in Respiratory Medicine, 4(1), 21–29. https://doi.org/10.2165/00151829-200504010-00003

Docherty, J. R. (2010). Subtypes of functional alpha1-adrenoceptor. Cellular and Molecular Life Sciences, 67(3), 405–417. https://doi.org/10.1007/s00018-009-0174-4

Johannssen, V., Maune, S., Werner, J. A., Rudert, H., & Ziegler, A. (1997). Alpha 1-receptors at pre-capillary resistance vessels of the human nasal mucosa. Rhinology, 35(4), 161–165.

Vaidyanathan, S., Williamson, P., Clearie, K., Khan, F., & Lipworth, B. (2010). Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion. American Journal of Respiratory and Critical Care Medicine, 182(1), 19–24. https://doi.org/10.1164/rccm.200911-1701OC

Varghese, M., Glaum, M. C., & Lockey, R. F. (2010). Drug-induced rhinitis. Clinical & Experimental Allergy, 40(3), 381–384. https://doi.org/10.1111/j.1365-2222.2009.03450.x

Corboz, M. R., Rivelli, M. A., Mingo, G. G., McLeod, R. L., Varty, L., Jia, Y., & Hey, J. A. (2008). Mechanism of decongestant activity of alpha 2-adrenoceptor agonists. Pulmonary Pharmacology & Therapeutics, 21(3), 449–454. https://doi.org/10.1016/j.pupt.2007.06.007

Wang, J., Mao, Z. F., & Cheng, L. (2024). Rise and fall of decongestants in treating nasal congestion-related diseases. Expert Opinion on Pharmacotherapy, 25(14), 1943–1951. https://doi.org/10.1080/14656566.2024.2411009

Shahar, E., Nassar, L., Kedem, E., & Hassoun, G. (2014). Alpha-1 adrenergic antagonists induced severe rhinitis in patients with benign prostatic hyperplasia. Current Drug Safety, 9(2), 159–160. https://doi.org/10.2174/1574886309666140527112408

van Waterschoot, J., Van Gerven, L., Pfirrman, S., Greiwe, J., & Bernstein, J. A. (2026). The diagnosis of non-allergic rhinitis. Immunology and Allergy Clinics of North America, 46(1), 27–48. https://doi.org/10.1016/j.iac.2025.09.003

Zeitlin, J., Shermetaro, C., & Sutton, A. E. (2026). Rhinitis medicamentosa. In StatPearls. StatPearls Publishing.

Graf, P. (1997). Rhinitis medicamentosa: Aspects of pathophysiology and treatment. Allergy, 52(Suppl. 40), 28–34. https://doi.org/10.1111/j.1398-9995.1997.tb04881.x

Mortuaire, G., de Gabory, L., François, M., Massé, G., Bloch, F., Brion, N., Jankowski, R., & Serrano, E. (2013). Rebound congestion and rhinitis medicamentosa: Nasal decongestants in clinical practice—Critical review of the literature by a medical panel. European Annals of Otorhinolaryngology, Head and Neck Diseases, 130(3), 137–144. https://doi.org/10.1016/j.anorl.2012.09.005

Christensen, L. K., Armstead, V. E., Bilyeu, D. P., Johnson, K. E., & Friesen, R. H. (2017). Hemodynamic responses and plasma phenylephrine concentrations associated with intranasal phenylephrine in children. Paediatric Anaesthesia, 27(7), 768–773. https://doi.org/10.1111/pan.13168

Eccles, R. (2007). Substitution of phenylephrine for pseudoephedrine as a nasal decongestant: An illogical way to control methamphetamine abuse. British Journal of Clinical Pharmacology, 63(1), 10–14. https://doi.org/10.1111/j.1365-2125.2006.02833.x

Lowry, J. A., & Brown, J. T. (2014). Significance of the imidazoline receptors in toxicology. Clinical Toxicology, 52(5), 454–469. https://doi.org/10.3109/15563650.2014.898770

Bucaretchi, F., Dragosavac, S., & Vieira, R. J. (2003). Exposição aguda a derivados imidazolínicos em crianças [Acute exposure to imidazoline derivatives in children]. Jornal de Pediatria, 79(6), 519–524.

Alvarez-Pitti, J., Rodríguez-Varela, A., Morales-Carpi, C., et al. (2006). Naphazoline intoxication in children. European Journal of Pediatrics, 165, 815–816. https://doi.org/10.1007/s00431-006-0185-1

Hol, M. K., & Huizing, E. H. (2000). Treatment of inferior turbinate pathology: A review and critical evaluation of the different techniques. Rhinology, 38(4), 157–166.

Nease, C. J., & Krempl, G. A. (2004). Radiofrequency treatment of turbinate hypertrophy: A randomized, blinded, placebo-controlled clinical trial. Otolaryngology–Head and Neck Surgery, 130(3), 291–299. https://doi.org/10.1016/j.otohns.2003.11.003

Passàli, D., Passàli, F. M., Damiani, V., Passàli, G. C., & Bellussi, L. (2003). Treatment of inferior turbinate hypertrophy: A randomized clinical trial. Annals of Otology, Rhinology & Laryngology, 112(8), 683–688. https://doi.org/10.1177/000348940311200806

Sapçi, T., Sahin, B., Karavus, A., & Akbulut, U. G. (2003). Comparison of the effects of radiofrequency tissue ablation, CO₂ laser ablation, and partial turbinectomy applications on nasal mucociliary functions. The Laryngoscope, 113(3), 514–519. https://doi.org/10.1097/00005537-200303000-00022

Harju, T., & Numminen, J. (2022). The long-term effect of inferior turbinate surgery techniques on nasal obstruction and quality of life. Annals of Otology, Rhinology & Laryngology, 131(9), 933–940. https://doi.org/10.1177/00034894211049573

Houser, S. M. (2006). Empty nose syndrome associated with middle turbinate resection. Otolaryngology–Head and Neck Surgery, 135(6), 972–973. https://doi.org/10.1016/j.otohns.2005.04.017

Cam, B., Sari, M., Midi, A., & Gergin, O. (2019). Xylitol treats nasal mucosa in rhinitis medicamentosa: An experimental rat model study. European Archives of Oto-Rhino-Laryngology, 276(11), 3123–3130. https://doi.org/10.1007/s00405-019-05605-3

Fokkens, W., Hellings, P., & Segboer, C. (2016). Capsaicin for rhinitis. Current Allergy and Asthma Reports, 16(8), Article 60. https://doi.org/10.1007/s11882-016-0638-1

Trivedi, B., Vyas, P., Soni, N. K., Gupta, P., & Dabaria, R. K. (2022). Is posterior nasal nerve neurectomy really a ray of hope for the patients of allergic rhinitis? Indian Journal of Otolaryngology and Head & Neck Surgery, 74(Suppl. 3), 4713–4717. https://doi.org/10.1007/s12070-021-03031-8

Chu, Y. H., Wu, C. C., Kao, C. H., & Wang, H. W. (2006). Low temperature decreased tension in isolated hypertrophic human nasal mucosa. American Journal of Rhinology, 20(1), 84–86.