When are steroids indicated in the treatment of strep throat?

When to Use Steroids in Strep Throat

Corticosteroids are NOT routinely recommended for strep throat, but can be considered in adults with severe presentations (Centor score 3-4) when used alongside appropriate antibiotic therapy. 1

Primary Guideline Position

The Infectious Diseases Society of America explicitly states that adjunctive corticosteroid therapy is not recommended for routine treatment of group A streptococcal pharyngitis (weak recommendation, moderate quality evidence). 1 This reflects the self-limited nature of the disease, availability of effective alternatives (NSAIDs/acetaminophen), and potential for adverse effects despite modest symptom benefits. 2

Exception: Severe Cases in Adults

Consider a single dose of corticosteroids ONLY in adults meeting ALL of the following criteria: 1, 3

• Centor score 3-4, which includes:

  • Fever (temperature >38°C)
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough 2

• Must be used in conjunction with appropriate antibiotic therapy (penicillin or amoxicillin for 10 days) 1, 3

• Dosing: Single oral dose of dexamethasone 10 mg 3

Clinical Benefits (When Used Appropriately)

In adults with severe sore throat (Centor 3-4), corticosteroids provide: 4, 5

• 2.4 times increased likelihood of complete pain resolution at 24 hours 4
• 1.5 times increased likelihood of pain resolution at 48 hours 4
• Mean time to pain relief reduced by 4.8-6 hours 4, 5
• Mean time to complete pain resolution reduced by 11.1-11.6 hours 4, 5
• Number needed to treat = 5 to prevent one person continuing to experience pain at 24 hours 4

However, the actual reduction in pain duration is only approximately 5 hours, which must be weighed against potential risks. 2

Populations Where Steroids Should NOT Be Used

Do not use corticosteroids in: 3, 2

• Children - No significant benefit has been demonstrated in pediatric populations 3
• Patients with Centor scores 0-2 (less severe presentations) 1, 2
• Patients with diabetes mellitus or glucose dysregulation 3
• Patients already on exogenous steroids 3
• Patients with endocrine disorders 3
• Routine or uncomplicated cases - The effect is considerably smaller in typical primary care populations where most patients do not have severe sore throat 3, 2

Preferred Standard Treatment Approach

For ALL patients with strep throat, the primary treatment should be: 1

• Antibiotics: Penicillin or amoxicillin for 10 days (first-line choice) 1
• Analgesics: Ibuprofen or acetaminophen for moderate to severe symptoms or high fever 1
• Avoid aspirin in children due to Reye syndrome risk 1

These systemic analgesics are effective for symptom management without steroid risks. 2

Critical Clinical Pitfalls

• Do not use steroids routinely - Studies were not sufficiently powered to detect adverse effects of short courses, and the modest benefit (approximately 5 hours of pain reduction) may not justify potential risks in most patients 3, 2

• Always discuss risks versus benefits with patients when considering steroids in severe adult cases, emphasizing the limited magnitude of benefit 1, 2

• The effect of steroids appears smaller when administered orally compared to other routes, though oral administration is most practical in outpatient settings 3

• Recurrent sore throat patients may accumulate larger cumulative steroid doses over time, which has not been adequately studied for safety 5