Are steroids used in the treatment of streptococcal (strep) throat?

Use of Steroids in Strep Throat

Corticosteroids are not routinely recommended for treatment of strep throat, but can be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotic therapy. 1

Evidence-Based Recommendations

Primary Treatment Approach

• The primary treatment for streptococcal pharyngitis is antibiotics, with penicillin and amoxicillin being first-line options 2, 3
• For symptomatic relief, ibuprofen or paracetamol are recommended as first-line agents 1

Role of Corticosteroids

Corticosteroids may be considered in specific circumstances:

• Adults with severe presentations: Patients meeting 3-4 Centor criteria (fever, tonsillar exudate, tender cervical lymphadenopathy, absence of cough) may benefit from a single dose of corticosteroids alongside antibiotics 1
• Not for routine use: The European Society of Clinical Microbiology and Infectious Diseases explicitly states that corticosteroids are not routinely recommended for treatment of sore throat 1
• Limited evidence in children: No significant benefit has been found for corticosteroid use in children with strep throat 1, 4

Clinical Evidence and Efficacy

A systematic review and meta-analysis demonstrated that:

• Corticosteroids increased the likelihood of complete pain resolution at 24 hours (RR 2.4) and at 48 hours (RR 1.5) 4
• The number needed to treat to prevent one person from continuing to experience pain at 24 hours is five 4
• Corticosteroids reduced mean time to onset of pain relief and complete resolution of pain by 6 and 11.6 hours, respectively 4
• Pain was reduced by an additional 10.6% at 24 hours with corticosteroids 4

Administration Considerations

If corticosteroids are used:

• Both oral and intramuscular routes appear to provide similar levels of pain relief 5
• A single dose is typically sufficient 1, 4
• The effect of steroids is smaller when administered orally compared to other routes 1

Important Caveats and Limitations

• Corticosteroids should only be used as an adjunct to appropriate antibiotic therapy in confirmed streptococcal pharyngitis, not as standalone treatment 1, 4
• The benefit of steroids might be considerably smaller in typical primary care populations where most patients do not have severe sore throat 1
• Studies have not been sufficiently powered to detect adverse effects of short courses of oral corticosteroids 1
• Recent guidelines from 2024 do not recommend steroids for symptomatic treatment of strep throat 3

Clinical Decision Algorithm

1. Assess severity using Centor criteria (fever, absence of cough, tonsillar exudate, tender anterior cervical lymphadenopathy)
2. For patients with score ≤2: Use antibiotics if indicated; avoid corticosteroids
3. For adult patients with score 3-4:
   • Prescribe appropriate antibiotic therapy
   • Consider a single dose of corticosteroid for symptomatic relief
   • Use ibuprofen or paracetamol for ongoing pain management
4. For children: Avoid corticosteroids; use appropriate antibiotics and symptomatic treatment with ibuprofen or paracetamol

In conclusion, while corticosteroids may provide modest symptomatic benefit in adults with severe strep throat, they should not be used routinely and should always be given in conjunction with appropriate antibiotic therapy when used.