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

Recommended Steroid Regimen for Bell's Palsy

Patients with Bell's palsy should be treated with oral prednisone 60-80mg daily for 7 days followed by a gradual taper, administered within 72 hours of symptom onset. 1

Treatment Protocol

First-line Treatment

• Oral corticosteroids:
  • Prednisone 60-80mg daily for 7 days followed by a gradual taper 1
  • Alternative regimen: Prednisone 50-60mg daily for 5 days followed by a 5-day taper 2
  • Must be initiated within 72 hours of symptom onset for maximum efficacy

Efficacy and Evidence

• High-quality evidence demonstrates that early corticosteroid administration improves recovery rates from 70% to 94% 1
• Corticosteroids are the cornerstone of Bell's palsy treatment with strong supporting evidence 1

Optional Adjunctive Therapy

• Antiviral therapy may be offered as an optional complement to steroid therapy:
  • Valacyclovir 1g three times daily for 7 days, OR
  • Acyclovir 400mg five times daily for 10 days 1
• Evidence for antiviral benefit is mixed (RR 0.75,95% CI 0.56-1.00) 1
• Antivirals alone are ineffective and not recommended 2

Special Considerations

Dosing Considerations

• Recent meta-analysis suggests high-dose corticosteroids (≥100mg prednisolone daily) may be more effective than standard doses (50-60mg) in reducing non-recovery at 6 months 3
• However, the American Academy of Otolaryngology-Head and Neck Surgery guidelines still recommend the standard 60-80mg daily dose 1

Route of Administration

• Recent evidence (2024) suggests single-dose intravenous methylprednisolone may lead to faster recovery at 1 month compared to oral prednisolone, particularly in patients with grade 4 Bell's palsy 4
• However, by 3 months, there was no significant difference between IV and oral administration 4
• Oral administration remains the standard of care based on guidelines 1

Pediatric Patients

• Evidence for corticosteroid use in children is less robust
• A 2022 randomized controlled trial did not demonstrate significant benefit of prednisolone (1mg/kg) over placebo in children 5
• Most children (93-99%) recover spontaneously by 6 months regardless of treatment 5

Mandatory Adjunctive Care

• Eye protection is essential for patients with impaired eye closure:
  • Artificial tears
  • Lubricating eye drops or ointments
  • Eye patches or adhesive tape
  • Humid chambers
  • Sunglasses for daytime protection 1

Follow-up Recommendations

• Patients should be reevaluated if they present with:
  • New or worsening neurological findings
  • Ocular symptoms
  • Incomplete facial recovery after 3 months 1
• Consider referral to a facial nerve specialist for patients with incomplete recovery 1

Common Pitfalls to Avoid

1. Delayed treatment: Corticosteroids must be initiated within 72 hours of symptom onset
2. Inadequate eye protection: Can lead to corneal damage in patients with impaired eye closure
3. Relying on antivirals alone: Not effective without concurrent steroid therapy
4. Misdiagnosis: Ensure diagnosis is consistent with Bell's palsy (acute onset <72 hours, unilateral facial weakness/paralysis, no other neurological deficits)
5. Inadequate follow-up: Patients with incomplete recovery after 3 months should be referred to specialists

The evidence strongly supports early corticosteroid administration as the most effective intervention for improving outcomes in Bell's palsy, with significant improvements in recovery rates when initiated promptly.