Background
Nearly 1 in 4 Americans experience chronic nasal congestion on a daily basis. For those that present to an otolaryngologist's office, nasal congestion or obstruction can be due to a wide variety of etiologies, with many resulting from an inflammatory, infectious, or anatomic cause, though commonly a combination. A first line treatment used to treat nasal congestion is often an intranasal corticosteroid (INCS) spray, but given the abundance of INCS sprays at the otolaryngologist's disposal, it begs the question: which is best?
The aim of this article was to review the available literature comparing INCS sprays for efficacy in relief of nasal congestion/obstruction.
Literature Review
In the United States, eight INCS sprays are FDA approved as of November 2025 (in order of FDA approval date, brand name(s) in parentheses): flunisolide, beclomethasone dipropionate monohydrate (Qnasl (Teva Pharmaceuticals USA Inc., Parsippany, NJ, USA)), fluticasone propionate (Flonase (GlaxoSmithKline, Warren, NJ)), triamcinolone acetonide (Nasocort (Chattem Inc., Chattanooga, TN)), mometasone furoate monohydrate (Nasonex (Perrigo Company plc, Dublin, Ireland)), budesonide (Rhinocort (McNeil Consumer Healthcare, Markham, Ontario)), ciclesonide (Omnaris (Covis Pharma GmbH, Berkley Heights, NJ)), and fluticasone furoate (Flonase Sensamist (GlaxoSmithKline, Warren, NJ)). Of these, budesonide, fluticasone propionate, mometasone furoate, and triamcinolone acetonide are available in a once‐daily dosing regimen—a characteristic that has been shown to improve patient adherence. In addition, the following five ICNSs are available over the counter (OTC): budesonide, fluticasone propionate, fluticasone furoate, mometasone furoate, and triamcinolone acetonide.
Limited head‐to‐head studies exist to directly compare INCSs with respect to nasal congestion/obstruction, but multiple studies compare efficacy in perennial allergic rhinitis. Allergic rhinitis is the most common FDA‐approved indication for this therapeutic class and is the indication for which it is first line according to the American Academy of Otolaryngology—Head and Neck Surgery Clinical Practice Guideline (results summarized in Table 1) [1]. Of note, the main comparison outcome in these studies is a combined nasal symptom score, but each compares nasal obstruction, albeit with inconsistent language (obstruction, blockage, congestion) and measurement (symptom score vs. peak nasal inspiratory flow [PNIF]).
Day et al. performed a multicenter, blinded, randomized, placebo‐controlled, parallel‐group trial of 314 adults with perennial allergic rhinitis comparing budesonide 256 mcg to fluticasone propionate 200 mcg to placebo, all once daily [4]. The primary outcome was a combined nasal symptom score (nasal blockage, runny nose, and sneezing). Both budesonide and fluticasone propionate groups had significant improvements in combined nasal symptom scores compared with placebo (p < 0.0001 and p = 0.0012, respectively).
The budesonide‐treated group showed significant improvement within 36 h after treatment compared with the placebo‐treated group (p = 0.01), whereas the fluticasone propionate‐treated group showed significant improvement within 60 h of treatment compared with the placebo‐treated group (p < 0.001). When comparing the two active treatment groups, there was a significantly greater improvement in the budesonide treated patients over the fluticasone propionate group in both total symptom score (p = 0.031) and nasal blockage (p = 0.009). Fluticasone had no significant improvement in nasal blockage scores against placebo.
Bende et al. performed a randomized, placebo‐controlled, parallel‐group trial of 438 adult patients with perennial allergic rhinitis comparing two doses of budesonide, 256 mcg or 128 mcg, to mometasone furoate 200 mcg or placebo, all once daily for 4 weeks [3]. Efficacy was evaluated via both a combined nasal symptom score (nasal blockage, runny nose, and sneezing) and peak nasal inspiratory flow (PNIF). All three treatments significantly reduced the nasal symptom score compared with placebo, with no difference between active treatments.
PNIF was significantly improved with all three active treatments: the effect of budesonide 256 mcg on morning and evening PNIF was significantly greater and approximately twice that of mometasone furoate and 128 mcg budesonide.
Mandl et al. performed a multicenter, double‐blind, randomized, placebo‐controlled, parallel‐group trial of 548 adult and adolescent (12–17 years old) patients with perennial allergic rhinitis, comparing mometasone furoate 200 mcg to fluticasone propionate 200 mcg to placebo, all once daily [5]. Efficacy was evaluated via a combined nasal symptom score (sneezing, rhinorrhea, nasal itch, and congestion). Both the mometasone furoate and the fluticasone propionate treatment groups produced significantly (p < 0.01) greater improvements in nasal symptom scores (15% and 13% for mometasone and fluticasone, respectively) than the placebo group.
There was no significant difference between the two steroids in either total nasal symptom score or nasal congestion score.
Haye et al. performed a multicenter, double‐blind, randomized, parallel‐group trial of 251 patients with perennial allergic rhinitis comparing fluticasone propionate 200 mcg to beclomethasone dipropionate 200 mcg, both twice daily [2]. Efficacy was evaluated via nasal symptom scores (nasal blockage, discharge, and itching). After 1 year of treatment, nasal blockage (p = 0.002) and nasal discharge (p = 0.002) were significantly improved in patients treated with fluticasone propionate over beclomethasone dipropionate.
Best Practice Summary
Based on the available data, it is not currently possible to draw definitive conclusions about the superiority of one INCS spray for congestion/nasal obstruction/blockage and, unfortunately, no data exist comparing ICNS sprays in nonallergic rhinitis. Data suggest that in patients with allergic rhinitis, all appear to be effective over placebo; however, limited studies suggest superiority of budesonide over fluticasone propionate and mometasone furoate, and of fluticasone propionate over beclomethasone dipropionate. Future studies to compare the use of multiple INCSs, both in spray and irrigation formulations, using validated standardized outcome measures, rhinomanometry, consistent terminology, and in both allergic and nonallergic rhinitis patients could guide future decision making for clinicians.
Level of Evidence
1, individual randomized controlled trials.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.