Reducing Inflammation With Steroids

Steroids get a lot of press because of their questionable use by weight lifters and other athletes to enhance performance. But you needn’t worry.

Those are anabolic steroids, which build muscle; the steroids used to treat nasal and sinus symptoms are an entirely different class of compound known as corticosteroids. Taking them won’t enable you to bench-press 350 pounds, but you’ll probably find they help you breathe better.

Steroids can be delivered to the nose in two ways: by spray or pill. Either way, they’re available only by prescription. Both forms are potent anti-inflammatory agents. Simply put, they reduce swelling.

Steroids act by passing through a cell’s membranes into its nucleus, stopping the process that causes inflammation at its source. Steroids are also the most effective tool we have for reducing nasal polyps, short of surgery.

Polyps’ size tends to vary depending on the individual’s place on the Sinusitis Spectrum (see Figure below).

Most Locals don’t have polyps, but if they do, the polyps tend to be small and located in or near the ostiomeatal complex (OMC). Intermediates often have larger polyps, which arise from the ethmoid sinuses and extend into the nasal cavity.

Systemics frequently have large polyps that obstruct all of the sinuses and block nasal breathing. Most of this article focuses on nasal steroid sprays, because they are widely used by people with sinusitis. At the end, I’ll address pills (oral steroids), which are used much less frequently due to their side effects.

Nasal Steroid Sprays

Nasal steroid sprays are a logical and common next step for many sinusitis patients whose symptoms do not respond to over-thecounter treatments. Spraying steroids directly into your nose delivers the steroid in relatively high concentration to the nasal membranes, where it can block inflammation from allergies and other causes.

A topical steroid spray can:

  • Reduce swelling of the turbinates and nasal membranes
  • Reduce nasal secretions, particularly those due to allergies
  • Shrink polyps

With swelling reduced and less secretions, you’re likely to breathe better. Also, there’s a good possibility that the OMC will open up, allowing your sinuses to drain and air to get in and out. In addition, shrinking polyps often means your sense of smell will improve if it’s been impaired.

Nasal Steroid FAQs

Here are answers to frequently asked questions about nasal steroid sprays.

  • How Long Does It Take for Steroids to Start Working? Patients often find they need to use steroid sprays for four or five days before they notice any benefits; unlike with spray decongestants, you should not expect an immediate effect.
  • Which Nasal Steroid Should I Use? Many different steroids are available by prescription. Flonase is the most well-known due to heavy advertising; others include Beconase, Nasacort, Nasarel, Nasonex, Rhinocort, and Vancenase (see Table below).

Commonly Prescribed Nasal Steroids

Name Active Ingredient
Beconase, Beconase AQ Beclomethasone
Flonase Fluticasone
Nasacort, Nasacort AQ Triamcinolone
Nasarel Flunisolide
Nasonex Mometasone
Rhinocort Aqua Budesonide
Vancenase, Vancenase AQ Beclomethasone

Although their active ingredients may differ, there is no clear evidence that one steroid spray is superior to any other. However, their effects do vary from person to person.

Many of patients sense no improvement using one brand and find good relief when they switch to another. Your doctor will prescribe the steroid spray he or she is most familiar with or believes will be most effective for you.

If one spray does not seem to be working after several weeks, talk to your doctor about switching to another brand to see if it makes a difference.

  • What Are the Potential Side Effects? Nasal steroid sprays should not have long-term side effects as long as you take the recommended dose. The active ingredient is absorbed through the nasal membranes in such minute amounts that body functions are unlikely to be disrupted.

Steroid sprays are among the most widely prescribed medications in the world, and people have taken them for years, even decades, without problems.

However, two short-term side effects occur in about one in five users: nosebleeds and a burning sensation in the nose. Both problems can usually be avoided if you exercise care when you spray.

The trick is to spray toward the outside of your nose, where the turbinates are. If you spray toward the inside, you’ll coat the septum, which has a surface rich in blood vessels that may become fragile and rupture with repeated exposure to the steroid.

A good technique for spraying the correct part of your nose is to use your opposite hand for each nostril; in other words, spray your left nostril with your right hand and your right nostril with your left hand.

A small study in 2003 by a Georgetown University professor found this sleight of hand nearly eliminated nosebleeds among a group of nasal spray users who had been experiencing two or three per week.

If you do experience nosebleeds, stop taking nasal steroids for two weeks to give the interior of your nose time to heal. Then you can resume use, carefully spraying toward the outside of your nose.

  • How Often Should I Use the Spray? The package includes instructions for a specific medication’s recommended usage. In the past, most were used twice a day, but the trend among drug manufacturers is toward once-a-day dosing in which you spray each nostril twice, at a time of your choosing.

Some people find it beneficial to split the dosage in half and spread it throughout the day. In other words, you can deliver one spray per nostril in the morning and one spray per nostril in the evening.

This tactic spreads out delivery of the active ingredient throughout the day but still provides the same total of four sprays each day, so there’s no risk of increased side effects.

  • Is It OK if I Skip Sprays on Days When I’m Not Congested? For maximum effectiveness, you should use steroid sprays every day. However, it’s not dangerous to skip days or stop and start sprays—it just may take a few days for their beneficial effects to kick in again.

Also, people with seasonal allergies often only use steroid sprays during the spring and fall when their symptoms flare up. That’s fine.

Oral Steroids

If nasal sprays are not effective, your doctor may prescribe oral steroids. Two are available—prednisone and methylprednisolone (known by the brand name Medrol)—with similar effectiveness and side effect profiles.

First, the good news. Oral steroids are powerful and highly effective in blocking inflammation of the nose and sinuses. Most people find they breathe much better and have less postnasal drip within twenty-four hours of their first dose.

Oral steroids also are highly effective at reducing large polyps. At a certain point, polyps get so large that nasal sprays are no longer effective. A short regimen of oral steroids can often shrink polyps enough that nasal steroid sprays will begin working again.

Now the bad news. Because oral steroids circulate throughout your body, long-term side effects are a major issue.

Prolonged use can lead to osteoporosis with weakened bones, thinning of the skin with easy bruising, and a compromised immune system with susceptibility to infection, as well as cataracts, stomach ulcers, fluid retention, and a host of other serious side effects.

When taken as a short course of less than a week, steroids only rarely have side effects, although some people do get insomnia or an upset stomach. But long-term use suppresses the adrenal glands’ ability to secrete natural steroids (such as cortisol) that are needed during periods of stress.

Therefore, when oral steroids are prescribed for more than one week, they are usually not stopped abruptly but by a gradual decrease in the daily dose. Tapering allows the adrenal glands to ramp up the body’s natural secretion of cortisol.

I advise patients against taking more than three courses of oral steroids per year. Along with the increased risk of side effects, repeated use often means a higher dose is required to achieve the same positive effects.

Oral steroids are neither a solution nor a cure for most people’s sinusitis, but they offer the best nonsurgical means of controlling symptoms for some Intermediates and Systemics. Steroids in spray or pill form are often used in conjunction with antibiotics.

Next, we’ll look at the many different antibiotics used to combat sinusitis.