What is the recommended steroid dosing regimen for facial palsy?

Steroid Dosing Regimen for Facial Palsy

For Bell's palsy, prescribe oral prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper, but only when initiated within 72 hours of symptom onset. 1, 2, 3

Timing of Treatment

• Steroids must be initiated within 72 hours of symptom onset to be effective 1, 2, 3
• Clinical trials demonstrating steroid efficacy specifically enrolled patients within this 72-hour window 1
• Starting steroid treatment beyond the 72-hour window provides minimal benefit while exposing patients to medication risks 1

Evidence for Effectiveness

• Strong evidence supports early corticosteroid use, with 83% recovery at 3 months with prednisolone vs 63.6% with placebo 3
• Long-term outcomes show 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 3
• Early treatment aims to reduce inflammation of the facial nerve before permanent damage occurs 1

Dosing Options

1. Preferred regimen options:

   • Prednisolone 50 mg daily for 10 days 1, 2, 3
   • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2, 3

2. Important considerations:

   • High-dose steroids have not shown more clinically meaningful outcomes than moderate or low-dose steroids in some studies 4
   • However, current guidelines still recommend the standard high-dose regimens listed above 1, 2, 3

Special Populations

Children

• Children have better prognosis with higher rates of spontaneous recovery than adults 1, 3
• Evidence for steroid use in children is less conclusive 3, 5
• A randomized trial showed that at 1 month, recovery rates were 49% with prednisolone vs 57% with placebo 5
• By 6 months, recovery rates were 99% with prednisolone vs 93% with placebo 5

Pregnant Women

• Treatment should be administered with careful assessment of benefits and risks 1, 3
• The same dosing regimen applies, but requires individualized risk-benefit assessment 3

Additional Management

• Eye protection is essential for patients with impaired eye closure to prevent corneal damage 1, 3
• Implement lubricating ophthalmic drops for daytime protection 1
• Use ophthalmic ointments for nighttime protection 1
• Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 1

Common Pitfalls

• Delaying treatment beyond 72 hours significantly reduces effectiveness 1, 2
• Using antiviral therapy alone is ineffective and not recommended 1, 2, 3
• Failing to provide adequate eye protection for patients with impaired eye closure 1, 3
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 3

Follow-up

• Monitor for recovery and consider referral if new or worsening neurologic findings develop 1, 3
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1, 3
• Refer to a facial nerve specialist if incomplete facial recovery persists 3 months after initial symptom onset 1, 2, 3