What is the recommended steroid regimen for Bell's palsy treatment?

Bell's Palsy Steroid Regimen

The recommended steroid regimen for Bell's palsy is oral prednisone 50-60 mg daily for 5 days followed by a 5-day taper, initiated within 72 hours of symptom onset. 1, 2

Treatment Algorithm

First-Line Treatment:

• Oral corticosteroids (start within 72 hours of symptom onset):
  • Prednisone 50-60 mg daily for 5 days, followed by a 5-day taper 2
  • Strong evidence supports this regimen with significantly improved recovery rates 1

Adjunctive Therapy Options:

• Consider adding an antiviral agent:
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 2
  • Note: Antiviral monotherapy is NOT recommended 1

Special Considerations:

• Timing is critical - treatment efficacy diminishes when started after 72 hours 1
• Benefits of combination therapy (steroid + antiviral) may be greatest in patients with severe facial paralysis 1
• Eye protection measures are essential for patients with incomplete eye closure 1

Evidence Analysis

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends oral corticosteroids as primary treatment for Bell's palsy in patients 16 years and older 1. This recommendation is based on high-quality evidence showing significantly improved recovery rates with early steroid administration.

While some research has explored higher steroid dosing, the most recent evidence-based guidelines maintain the standard regimen of prednisone 50-60 mg daily for 5 days followed by a taper 1, 2. A 2023 systematic review suggested potential benefits of high-dose corticosteroids (≥80 mg daily) compared to standard doses, but noted serious risk of bias in all included studies 3.

Important Clinical Pearls

• Patient selection: Ensure Bell's palsy diagnosis is correct (acute onset, unilateral facial weakness/paralysis including forehead involvement, absence of other neurologic abnormalities) 1, 2
• Contraindications: Consider patient-specific factors such as diabetes, pregnancy, or previous steroid intolerance 1
• Follow-up: Reevaluate patients who develop new/worsening neurologic findings or have incomplete recovery after 3 months 1
• Prognosis: Without treatment, 70-94% of patients recover completely, but early steroid therapy significantly improves outcomes 1

Common Pitfalls to Avoid

1. Delayed treatment - Benefits diminish significantly when steroids are started after 72 hours 1
2. Using antivirals alone - Antiviral monotherapy is ineffective and not recommended 1, 2
3. Neglecting eye protection - Patients with incomplete eye closure require measures to prevent corneal damage (artificial tears, ocular ointment, eye patching/taping) 1
4. Missing other causes of facial paralysis - Bell's palsy is a diagnosis of exclusion; rule out stroke, tumors, and other conditions 1