Why are corticosteroids not recommended for treating strep (streptococcal) throat?

Why Corticosteroids Are Not Recommended for Strep Throat

Corticosteroids are not recommended for treating strep throat because they provide only minimal clinical benefit (approximately 5 hours of symptom reduction) that does not justify the potential risks of systemic steroid use, especially given that antibiotics and analgesics are already highly effective for this self-limited condition. 1

The Risk-Benefit Analysis

The Infectious Diseases Society of America explicitly recommends against adjunctive corticosteroid therapy for Group A streptococcal (GAS) pharyngitis 1, 2. This recommendation is based on several key considerations:

Minimal Clinical Benefit

• While corticosteroids do reduce pain duration, the actual decrease is only approximately 5 hours—a clinically insignificant improvement when weighed against potential harms 1
• The self-limited nature of GAS pharyngitis means most patients recover quickly with appropriate antibiotics alone 1
• Effective alternatives already exist: systemic analgesics (acetaminophen, NSAIDs) and topical anesthetics provide adequate symptom relief without steroid-related risks 1, 3

Potential for Adverse Effects

• Although short-term adverse effects were not evident in published studies, long-term follow-up data on steroid use in pharyngitis patients has not been adequately conducted 1
• The potential adverse effects of systemic steroids—including immunosuppression, glucose dysregulation, mood changes, and other systemic effects—outweigh the marginal symptomatic benefit 1
• This is particularly concerning in children, where steroid safety data is even more limited 4

What Works Instead

First-Line Antimicrobial Therapy

• Penicillin or amoxicillin for 10 days effectively treats GAS pharyngitis and prevents complications 3, 2
• Antibiotics shorten symptom duration by 1-2 days, reduce complications, and decrease contagiousness 3

Appropriate Symptomatic Management

• NSAIDs (such as ibuprofen) are more effective than acetaminophen for fever and pain control and should be the preferred analgesic 1, 5
• Acetaminophen is also effective and appropriate, particularly in breastfeeding mothers 2
• Topical anesthetics (ambroxol, lidocaine, benzocaine) and warm salt water gargles provide additional symptomatic relief 1, 3
• Aspirin must be avoided in children due to Reye syndrome risk 1, 3

Common Pitfalls to Avoid

• Do not prescribe corticosteroids routinely for symptomatic relief—the 5-hour reduction in pain does not justify the intervention 1, 5
• Do not assume that more aggressive symptom management requires steroids when effective and safer alternatives (NSAIDs, topical agents) are available 1, 3
• Avoid the temptation to add steroids for patients with severe symptoms—appropriate antibiotics and analgesics are sufficient 1

The Evidence Context

Research does show that corticosteroids can increase complete pain resolution at 24 hours by 2.4 times and at 48 hours by 1.5 times when added to antibiotics 4, 6. However, these studies have important limitations:

• Most trials studied steroids in combination with antibiotics, not as standalone therapy 4, 6
• Only one trial was conducted in primary care settings 7
• The absolute benefit translates to only 5-6 hours of reduced pain duration 1, 6
• Adverse event reporting was poor across studies, and few included children 4

The guideline consensus is clear: given the efficacy of antimicrobials, the self-limited nature of strep throat, and the availability of effective analgesics, corticosteroids should not be used for this illness. 1, 2