Steroids for Mono Pharyngitis: Not Recommended
Corticosteroids should NOT be routinely used for infectious mononucleosis pharyngitis, as they provide minimal clinical benefit (approximately 5 hours of symptom reduction) and carry potential risks that outweigh any marginal advantages. 1, 2, 3
When Steroids Are NOT Indicated
Routine symptom management: The Infectious Diseases Society of America explicitly recommends against corticosteroids for typical infectious mononucleosis symptoms including sore throat, fever, and lymphadenopathy (weak recommendation, moderate quality evidence). 2, 3
General pharyngitis pain: Corticosteroids reduce pain duration by only approximately 5 hours—a clinically insignificant improvement when balanced against potential adverse effects including immunosuppression, glucose dysregulation, and mood changes. 2, 3
Combination with antivirals: Antiviral therapy has no proven benefit in infectious mononucleosis, and adding corticosteroids to antivirals is not recommended for common symptoms. 4, 5
When Steroids MAY Be Indicated (Rare Circumstances)
Corticosteroids should be reserved exclusively for severe, life-threatening complications:
Impending airway obstruction from severe tonsillar enlargement or pharyngeal edema 4, 5, 6
Severe autoimmune complications (e.g., severe thrombocytopenia, hemolytic anemia) 5
Other critical circumstances requiring intensive care 4
Suggested Regimen for Severe Complications (When Indicated)
While guidelines do not specify exact dosing for mono-related airway obstruction, typical practice based on severe pharyngeal inflammation includes:
- Dexamethasone 10 mg IV/PO once, or
- Prednisone 40-60 mg PO daily for 3-5 days with rapid taper 6
Important caveat: This should only be used when benefits clearly outweigh risks, typically in hospital settings with close monitoring. 4, 5
Recommended First-Line Management
Symptomatic Treatment (Preferred Approach)
NSAIDs (ibuprofen): More effective than acetaminophen for fever and pain control; should be the preferred analgesic. 2, 3
Acetaminophen: Effective alternative, particularly appropriate in specific populations (e.g., breastfeeding mothers). 2, 3
Topical anesthetics: Lozenges containing ambroxol, lidocaine, or benzocaine provide temporary relief. 2, 3
Warm salt water gargles: Can provide symptomatic relief in patients old enough to gargle. 2, 3
Supportive Care
Adequate hydration and rest: Activity should be guided by the patient's energy level, not enforced bed rest. 6
Avoid contact/collision sports: Withdraw from such activities for at least 4 weeks after symptom onset due to splenic rupture risk. 6
Evidence Quality and Nuances
Cochrane review findings: A 2015 systematic review of 7 trials (362 participants) found insufficient evidence for steroid efficacy, with only 2/10 assessments showing any benefit, and that benefit was not maintained beyond 12 hours. 7
Safety concerns: While a 2025 retrospective study of 396 patients found corticosteroids "generally safe" when used with antibiotics, this should not encourage their use given unproven efficacy. 8 Long-term follow-up data on steroid use in pharyngitis remains inadequate. 3
Self-limited disease: Infectious mononucleosis typically resolves over 2-3 weeks without specific treatment, making aggressive interventions unnecessary for most patients. 4, 7
Common Pitfalls to Avoid
Do not prescribe steroids for patient or parent pressure: The 5-hour pain reduction does not justify intervention when safer alternatives exist. 2, 3
Do not assume severe symptoms require steroids: Appropriate analgesics (NSAIDs) and supportive care are sufficient for even significant pharyngitis. 3
Do not use steroids prophylactically: Reserve for documented severe complications, not anticipated problems. 5