Managing the Common Cold: What Works, What Doesn’t, and Why It Matters

Managing the Common Cold: What Works, What Doesn’t, and Why It Matters

The common cold refers to a mild upper respiratory viral illness that is self-limited and is caused by over 200 subtypes of viruses. It is a separate and distinct illness than influenza, COVID-19, pertussis, pharyngitis, acute bacterial rhinosinusitis, and acute bronchitis.  The common cold is associated with a staggering economic burden related to lost productivity and expenditures for treatment. A study over 20 years ago found that the economic cost of lost productivity due to the common cold approaches $25 billion per year. It is responsible for 40% of all time lost from jobs, with approximately 23 million workdays and 26 million school days lost each year. In preschool, the average incidence of the common cold is five to seven episodes per year, decreasing to two to three per year by adulthood.

What Causes the Common Cold?

The common cold is caused by a large group of viruses, with over 200 subtypes identified. The most common, Rhinovirus, has over 100 subtypes and causes about 30 to 50 percent of colds. Coronaviruses (excluding SARS-CoV-2, the virus that causes COVID-19) cause about 10 to 15 percent, with parainfluenza virus, adenoviruses and enteroviruses, among others, also contributing.

Symptoms

The hallmark symptoms of a cold are nasal congestion and rhinorrhea (runny nose), both of which are often accompanied by a dry or scratchy throat. A cough is also common, typically appearing after nasal symptoms have set in. The cough may linger even after other cold symptoms have resolved.

Other frequent complaints include sore throat, malaise (feeling unwell), headaches,  discomfort or pressure in the ears and face and sneezing. If present, fever is typically low grade. Most of the symptoms reflect the body’s immune response to the infection rather than direct damage to the respiratory tract.

Does Nasal Discharge Color Matter?

Nasal discharge can range from clear to yellow or green, but the color of the mucus is not a reliable indicator of whether antibiotics are needed. Colored nasal discharge is actually a normal part of the cold’s progression.

Diagnosis

The diagnosis of the common cold is based on reported symptoms and observed clinical findings on physical exam. Common findings include conjunctival injection (blood shot eyes), nasal mucosal swelling, nasal congestion and pharyngeal erythema ( red throat). The lung examination is typically clear.

In the absence of physical examination findings suggestive of pneumonia, chest imaging with x-ray or CT scan is not routinely indicated.

There are molecular assays that can detect many viruses that cause the common cold, but there are no targeted antiviral therapies currently approved for use outside of influenza and SARS-CoV-2, so in the absence of severe illness with the need for hospitalization, these are not routinely performed in the outpatient setting.

Treatment

For most people, symptoms of the common cold are self-limited and resolve on their own in up to one and a half weeks. Occasionally, patients may develop complications such as lower respiratory tract disease, asthma exacerbation, sinusitis, or acute otitis media.

There have been many studies looking at the treatment of the common cold, often with inconsistencies in findings thought to be due to fluctuating definitions of disease, variable age ranges, different measured symptom outcomes, etc.

Mild Symptoms

For those with mild symptoms, most patients do not require any symptomatic treatment, and should monitor their condition and return if they worsen or do not improve in the expected time period.

Moderate to Severe Symptoms

Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs like ibuprofen etc) may help to reduce symptoms including muscle aches, headache, ear discomfort. In one study, these medications were found to be more effective than placebo in reducing headache, achiness, and feverish discomfort.

Antihistamine/decongestant combinations such as Cetirizine/Pseudoephedrine may offer more benefit than either medication used alone. One review found that the number of patients needed to treat for symptom benefit compared with placebo was 3.9. (For every 3.9 patients that are treated with an antihistamine/decongestant combination, 1 patient would be expected to have symptom benefit).

Dextromethorphan is commonly used to help decrease the cough associated with the common cold, but evidence of benefit is limited. Various studies have found mixed results and even in those in which a benefit was seen, dextromethorphan offered only a 12 to 36 percent reduction in cough events. At least several studies have shown that cough suppressants are no more effective than placebo.

Decongestants such as pseudoephedrine may provide mild relief of nasal congestion. One study found a 6 percent decrease in symptoms compared with placebo. Oral phenylephrine was found by the FDA to be ineffective as a nasal decongestant. Topical decongestants containing phenylephrine may provide symptom benefit but should be limited to only two to three days at a time, due to the risk of rebound nasal congestion. 

Expectorants, such as guaifenesin, may offer a mild improvement in symptoms compared to placebo. It works by helping to thin the mucus in the airway passages to make it easier to cough up the mucus and clear the airways.

Saline nasal sprays can help to thin the mucus in the nasal passage improving congestion. There has been limited evidence of benefit historically, but a recent study found that in children, using saline nasal sprays within 24 hours of cold symptoms was associated with recovery two days earlier than in those who didn’t use it.

Zinc may decrease cold symptom severity as well as duration, but is not commonly recommended over concerns of adverse effects including poor taste, nausea, and irreversible anosmia (loss of smell) when given intranasally. A systematic review of 34 trials that looked at zinc for preventing or treating the common cold found that it offered no significant reduction in cold events, but may reduce symptom duration in some people.

Numerous studies have looked at Vitamin C as a potential natural treatment for the common cold. Similar to other treatments, the data is often of questionable quality and opposing in findings. A 2013 meta-analysis of 29 trials involving over 11,000 patients showed only a small reduction in the duration of cold symptoms in adults regularly taking Vitamin C supplements of at least 200 mg per day, as well as a reduction in severity of symptoms when colds did occur. In 2023 another meta-analysis showed that Vitamin C use may reduce the severity of cold symptoms by 15 percent.

Ineffective Treatments

Antihistamines used alone offers minimal benefit with frequent adverse reactions. Diphenhydramine (Benadryl) is a first-generation antihistamine, and may help improve a runny nose and sneezing, but may also cause sedation, dry eyes, mouth and nose. A systematic review of 18 trials found that antihistamines improved the severity of symptoms slightly more than placebo for the first one to two days of treatment, but offered no benefit after six to ten days of treatment. 

Antibiotics have no role in the treatment of the common cold in the absence of evidence of secondary bacterial infections. The common cold is caused by viruses and antibiotic use in this setting has been shown to cause more harm than benefit.

A systematic review of randomized trials in patients with upper respiratory symptoms for less than seven days found that the persistence of symptoms was identical in groups who received antibiotics or placebo. Antibiotics had a significantly greater risk of adverse effects. Despite this, antibiotics have historically been prescribed inappropriately in this setting. A large study of over 180,000 patients aged 66 and older with nonbacterial upper respiratory infections found that 46 percent were given an antibiotic.

While antibiotics play an important role in the treatment of bacterial infections, there are real possible adverse reactions with their use and should only be used when the benefit outweighs the risk. Common side effects include nausea, vomiting, diarrhea, allergic reactions, and drug interactions. One potentially serious and sometimes fatal complication is an antibiotic-associated colitis due to the bacteria Clostridiodides difficile, commonly called “C diff”. It is associated with antibiotic use, as there is a disruption of the normal colon bacteria that allows for the “C diff” bacteria to multiply and release toxins. The infection is associated with abdominal pain, severe diarrhea and can progress to a fulminant colitis requiring hospitalization, surgery, and may be fatal.

Antibiotic resistance is a growing public health concern, and refers to when bacteria change and become resistant to the effects of antibiotics, making it difficult to treat bacterial infections. According to the CDC, more than 2.8 million antimicrobial-resistance infections occur each year and more than 35,000 people die as a result.

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare but severe mucocutaneous reactions triggered by medications in most cases, including certain antibiotics. They are characterized by extensive necrosis and detachment of the outermost layer of the skin, with a mortality rate of approximately 25 percent.

Antiviral Therapies 

The common cold has a wide array of viral causes and studies have been relatively inconclusive regarding the benefit of antiviral therapy. In contrast, influenza and COVID-19 are caused by specific viruses, of which there has been shown to be a benefit in certain circumstances for targeted antiviral treatment. 

Conclusion

The common cold, while typically mild and self-limited, remains one of the most frequent illnesses that impacts daily life, contributing significantly to lost productivity and treatment costs.

In terms of treatment, most people with a cold recover within one to two weeks with minimal medical intervention. Symptomatic relief through over-the-counter medications, such as acetaminophen or decongestants, can help manage discomfort. However, it’s important to remember that antibiotics are ineffective against viral infections caused by the common cold, and their overuse can lead to serious health risks, including antibiotic resistance and harmful side effects.

Ultimately, prevention remains key. While there is no current cure for the common cold, maintaining good hygiene practices, such as frequent handwashing and avoiding close contact with infected individuals, can reduce the spread of the virus.

Although many people will recover on their own with minimal intervention, symptom management should be tailored to the individual's specific needs and circumstances. Anyone experiencing serious, prolonged or worsening symptoms, or those at higher risk for complications should consult their physician. A good history and physical examination, along with an understanding of potential complications can help create the most appropriate treatment plan.

Florida Direct Primary Care

At Florida Direct Primary Care, we develop individualized treatment plans that promote overall health and wellness, tailored to each patient’s unique health needs and goals. If you’re in the St. Augustine area and looking for a primary care, sports medicine, or obesity medicine doctor, contact us to learn more about the practice. Visit FloridaDPC.com, email us at info@FloridaDPC.com, or call 904-650-2882.

This web site is provided for educational and informational purposes only and does not constitute the provision of medical advice or professional services. The information provided should not be used for diagnosing or treating individual health problems or diseases. Those seeking medical advice should consult with a licensed physician.

Ready to become a Florida DPC member? Click here to register.