What is the recommended dose and duration of prednisone (corticosteroid) for treating Bell's palsy?

Prednisone Treatment for Bell's Palsy

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

Dosing and Duration

• Recommended regimen:
  • Prednisone 60-80mg daily for 7 days, followed by a gradual taper 1
  • Treatment must be initiated within 72 hours of symptom onset for maximum effectiveness 1

Evidence Supporting Corticosteroid Use

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends oral corticosteroids as the cornerstone of Bell's palsy treatment, with high-quality evidence demonstrating significant improvement in recovery rates from 70% to 94% 1.

Research supports this recommendation:

• In a double-blind, placebo-controlled trial, patients treated with prednisolone had significantly higher recovery rates at 3 months (83.0%) compared to those not receiving prednisolone (63.6%) 2
• The number needed to treat (NNT) to achieve one additional complete recovery was only 6 patients 3
• At 9 months, recovery rates were 94.4% for prednisolone versus 81.6% for no prednisolone 3

Timing of Treatment

The timing of corticosteroid administration is crucial:

• Patients treated within 24 hours had 66% complete recovery rate
• Patients treated within 25-48 hours had 76% complete recovery rate
• Both significantly better than patients not receiving prednisolone (51% and 58% respectively) 4
• No significant benefit was observed when treatment was started after 48 hours 4

Dosage Considerations

While the standard recommended dose is 60-80mg daily, some research has explored higher doses:

• A meta-analysis found that high-dose corticosteroids (initial prednisolone ≥100mg daily) were associated with decreased nonrecovery compared to standard doses (50-60mg) 5
• However, this evidence is of very low quality, and the American Academy of Otolaryngology-Head and Neck Surgery guidelines still recommend the 60-80mg daily dose 1, 5

Antiviral Therapy

• Antiviral therapy (such as acyclovir) is optionally recommended
• Evidence shows minimal additional benefit when combined with steroids 1
• Studies have not demonstrated significant improvement with acyclovir alone (71.2% recovery) versus no acyclovir (75.7% recovery) 2

Important Clinical Considerations

• Mandatory eye protection is essential for patients with impaired eye closure 1
• Use the House-Brackmann scale (grades 1-6) to quantify facial nerve function and monitor progress 1
• Refer patients to a facial nerve specialist if:
  • Swallowing difficulties persist beyond 3 months
  • Incomplete facial recovery after 3 months
  • New or worsening neurological findings
  • Ocular symptoms develop 1

Common Pitfalls to Avoid

1. Delayed treatment: Starting treatment after 48 hours significantly reduces effectiveness 4
2. Inadequate eye protection: Patients with impaired eye closure require mandatory eye protection to prevent corneal damage 1
3. Missing follow-up: Patients with incomplete recovery after 3 months should be referred to specialists 1
4. Relying solely on antivirals: Antivirals alone have not shown significant benefit and should not replace corticosteroids 1, 2, 3

Early treatment with appropriate doses of prednisone significantly improves outcomes in Bell's palsy, with the greatest benefit seen when initiated within 48 hours of symptom onset.