This patient’s presentation is consistent with rhinitis medicamentosa (RM), which is most commonly due to overuse of over-the-counter nasal decongestant sprays. The spray’s vasoconstrictive effect requires increasing amounts of the drug for symptomatic relief due to tachyphylaxis and leads to rebound vasodilation with swelling and rhinorrhea. Patients then use more nasal decongestant spray to relieve their symptoms, which begins a cycle of congestion with temporary relief followed by worsening congestion as the spray wears off. Patients also get an emotional lift from the spray and eventually become dependent on the drug.
The nasal irritation may be worsened by the benzalkonium chloride preservative present in many sprays. Diagnosis is made by history and physical examination showing swollen red nasal mucosa. Treatment involves medication cessation, which may be difficult since patients experience worsening rebound symptoms. Some data suggest that intranasal fluticasone use for a few days helps to alleviate the withdrawal nasal congestion. Some patients require oral steroids for more severe withdrawal symptoms. Rhinitis medicamentosa can be prevented by limiting over-the-counter nasal decongestant spray use to < 5 days.