No Role for Corticosteroids in Severe Scorpion Bites
Corticosteroids (including methylprednisolone) should not be used in the treatment of scorpion stings, regardless of severity, as they provide no clinical benefit and may increase costs and potential harm. 1
Evidence Against Corticosteroid Use
The most definitive evidence comes from a large randomized controlled trial that directly addressed this question:
- A randomized trial of 600 scorpion envenomation patients comparing high-dose intravenous hydrocortisone hemisuccinate (50 mg/kg) versus placebo found no significant difference in mortality, change in severity grade at 4 hours, or duration of hospital stay between groups 1
- The steroid group showed no improvement in preventing progression from local symptoms (grade 1) to systemic symptoms (grade 2) compared to placebo 1
- Mortality was identical in both groups (one death each), demonstrating no survival benefit 1
- The use of steroids added nearly $1 million in unnecessary costs without clinical benefit 1
Current Guideline Recommendations
The 2024 American Heart Association and American Red Cross Guidelines for First Aid make no mention of corticosteroids in their comprehensive recommendations for scorpion sting management 2. Their evidence-based recommendations focus exclusively on:
- Over-the-counter acetaminophen and NSAIDs for pain control 2
- Topical lidocaine (5%) if skin is intact 2
- Ice application for local pain relief 2
- Emergency services for systemic symptoms (difficulty breathing, muscle rigidity, dizziness, confusion) 2
Additional Supporting Evidence
- A matched-pair study of 135 patients found that while some patients received corticosteroids as adjunctive therapy, there was no demonstrated benefit from their use 3
- A pediatric protocol study that significantly reduced mortality in scorpion stings used prazosin and dobutamine as primary agents; notably, mortality was actually higher in children who received steroids outside the hospital before arrival 4
- A systematic review and meta-analysis of scorpion sting management identified effective treatments (antivenom, prazosin) but found no evidence supporting corticosteroid use 5
What Actually Works
For severe scorpion envenomation with systemic symptoms:
- Antivenom is the only specific etiological treatment and should be administered early when available 6, 5
- Prazosin (30 mcg/kg/dose every 6 hours) is effective for systemic manifestations, particularly for Mesobuthus tamulus stings 4, 5
- Dobutamine and sodium nitroprusside for acute pulmonary edema and myocarditis complications 4
- The combination of antivenom plus prazosin is superior to prazosin alone for faster symptom resolution (mean difference -12.59 hours) 5
Common Pitfall to Avoid
Do not prescribe corticosteroids based on the severity of symptoms or the presence of systemic manifestations—the evidence clearly demonstrates they are ineffective regardless of clinical severity 1. The reflexive use of steroids for "inflammation" in envenomation is not supported by evidence and wastes resources while potentially exposing patients to steroid-related adverse effects without benefit.