What is the role of steroids in treating acute pharyngitis?

Role of Steroids in Acute Pharyngitis

Corticosteroids can be considered for adult patients with severe acute pharyngitis (Centor score 3-4) as adjunctive therapy alongside antibiotics, but should NOT be routinely prescribed for all cases of sore throat.

Clinical Decision Algorithm

When to Consider Steroids

For Adults with Severe Presentations:

• Consider a single dose of corticosteroids ONLY in adults with severe sore throat (Centor criteria 3-4) when used in conjunction with antibiotic therapy 1
• The benefit is modest—approximately 5 hours reduction in pain duration 2
• Steroids provide statistically significant faster pain resolution compared to placebo, typically within 12-24 hours 3, 4

When NOT to Use Steroids:

• Do NOT routinely prescribe for all cases of acute pharyngitis 1, 2
• Do NOT use in children—no significant benefit has been demonstrated 1
• Avoid in patients with hoarseness or dysphonia, as there is a preponderance of harm over benefit 5

Evidence Quality and Nuances

The evidence presents a nuanced picture. While systematic reviews show steroids reduce pain in acute pharyngitis 6, 4, the Infectious Diseases Society of America explicitly recommends AGAINST corticosteroids as adjunctive therapy for Group A Streptococcal pharyngitis (weak recommendation, moderate quality evidence) 2. This reflects the tension between symptom relief and the self-limited nature of the disease.

The American College of Physicians takes a middle ground, suggesting consideration only in severe cases 1. The effect is considerably smaller in typical primary care populations where most patients do not have severe presentations 1.

Critical Safety Concerns

Major Pitfall—Undiagnosed Malignancy:

• Never prescribe steroids without careful examination for hepatosplenomegaly or lymphadenopathy outside the cervical region 7
• Steroids can mask acute lymphocytic leukemia (ALL) or lymphoma presenting as pharyngitis, potentially affecting curability 7
• If considering steroids in children (which is generally not recommended), obtain a complete blood count first to rule out ALL 7

Other Documented Adverse Effects:

• Short- and long-term steroid use carries risks including hypertension, cardiovascular disease, osteoporosis, impaired wound healing, infections, mood disorders, and diabetes 5
• Studies were not sufficiently powered to detect adverse effects of short courses 1

Preferred Pain Management Strategy

First-Line Approach (Instead of Steroids):

• Prescribe ibuprofen or acetaminophen as first-line adjunctive therapy alongside appropriate antibiotics (strong recommendation, high quality evidence) 2
• NSAIDs like ibuprofen demonstrate significant benefits in reducing fever and pain 2
• Topical agents containing local anesthetics (ambroxol, lidocaine, benzocaine) may provide temporary relief 2
• Avoid aspirin in children due to Reye syndrome risk 2

Practical Implementation

If You Decide to Use Steroids (Adults with Centor 3-4 only):

• Use a single dose approach 1
• Options include: dexamethasone, betamethasone, or prednisone 60 mg orally for 1-2 days 3, 4
• Must be combined with appropriate antibiotic therapy 1, 2
• Discuss the modest benefits (approximately 5 hours faster pain relief) against possible side effects 2

The Bottom Line: Given that traditional analgesics (NSAIDs, acetaminophen) are safe, effective, and do not carry the risks associated with steroids, routine use of corticosteroids in acute pharyngitis should be avoided 2, 7. Reserve consideration only for carefully selected adult patients with severe presentations, after ruling out contraindications, and always in conjunction with antibiotics 1, 2.