What is the recommended prednisone dose and treatment duration for acute pharyngitis in adults and children, and what are the indications and contraindications for its use?

Prednisone Dosing for Pharyngitis

Corticosteroids are not routinely recommended for acute pharyngitis, but a single oral dose of dexamethasone 10 mg (or prednisone 60 mg) can be considered in adults with severe presentations (Centor score 3-4) when used alongside appropriate antibiotic therapy. 1

Key Guideline Divergence

There is explicit disagreement between major societies on corticosteroid use:

• The American College of Physicians and European Society of Clinical Microbiology endorse considering a single dose of corticosteroids in severe adult cases (Centor 3-4) when combined with antibiotics 1
• The Infectious Diseases Society of America does not recommend corticosteroids as adjunctive therapy for Group A Streptococcal pharyngitis 2, 3

This divergence reflects the modest clinical benefit versus concerns about routine steroid exposure.

Specific Dosing Regimens

Adults

• Dexamethasone 10 mg orally as a single dose (preferred due to potency and convenience) 1
• Prednisone 60 mg orally for 1-2 days (alternative option) 4

Children

• Dexamethasone 0.6 mg/kg orally (maximum 10 mg) as a single dose for severe or exudative Group A Streptococcus-positive pharyngitis 5
• Note: No significant benefit has been demonstrated in children overall, so use should be highly selective 1

Patient Selection Criteria

Only consider corticosteroids in patients meeting ALL of the following:

• Adults with Centor score 3-4 (fever history, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1, 6
• Severe presentation with significant pain and functional impairment 1
• No contraindications (see below) 1

Do NOT use corticosteroids in:

• Patients with mild presentations (Centor 0-2) 1
• Routine or uncomplicated cases 3, 7
• Children without severe exudative disease 1, 5

Mandatory Concurrent Therapy

Corticosteroids must NEVER be used as monotherapy. When prescribed, they require:

Antibiotic Coverage

• Penicillin V 500 mg orally twice daily for 10 days (first-line) 3
• Amoxicillin 500 mg orally twice daily for 10 days (equally effective alternative) 3
• The full 10-day antibiotic course is essential even when adding steroids 3, 1

First-Line Analgesics

• Ibuprofen or acetaminophen should be prescribed for all patients regardless of steroid use 3, 1
• NSAIDs are more effective than acetaminophen for pharyngitis pain 7

Absolute Contraindications

Do NOT prescribe corticosteroids in patients with:

• Diabetes mellitus or glucose dysregulation 1
• Current exogenous steroid use 1
• Endocrine disorders 1
• Anaphylactic penicillin allergy (if unable to provide alternative antibiotic coverage) 3

Expected Clinical Benefit

The benefit of corticosteroids is modest and should be discussed with patients:

• Pain relief accelerated by approximately 5 hours compared to antibiotics alone 1
• Faster onset of pain relief in severe cases, particularly with exudative disease 5, 4
• Effect is smaller when given orally compared to other routes 1
• Effect is considerably smaller in typical primary care populations where most patients do not have severe presentations 1

Critical Pitfalls to Avoid

• Never prescribe corticosteroids without confirming bacterial pharyngitis and initiating appropriate antibiotic therapy 1
• Never use corticosteroids routinely for all sore throat cases—reserve for severe presentations only 3, 1, 7
• Never shorten the antibiotic course when adding steroids; the full 10-day regimen remains mandatory 3
• Never extrapolate perioperative tonsillectomy dosing (0.5 mg/kg IV intraoperatively) to medical management of acute pharyngitis 1
• Studies were not adequately powered to detect adverse effects of short-course steroids, so use cautiously 1

Practical Algorithm

1. Confirm bacterial pharyngitis with rapid antigen detection test or throat culture 3
2. Calculate Centor score (fever, exudates, no cough, tender nodes) 1, 6
3. If Centor 3-4 AND severe symptoms:
   • Prescribe penicillin or amoxicillin for 10 days 3
   • Add ibuprofen or acetaminophen 3, 1
   • Consider single-dose dexamethasone 10 mg after discussing modest benefit 1
4. If Centor 0-2 or mild symptoms:
   • Prescribe antibiotics and analgesics only 3, 1
   • Do NOT add corticosteroids 1