What is the recommended steroid dosing and tapering regimen for facial palsy, specifically Bell's (Bell's) palsy, using prednisolone (prednisolone) or prednisone (prednisone)?

Steroid Dosing and Tapering Regimen for Bell's Palsy

For Bell's palsy, oral prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper should be prescribed within 72 hours of symptom onset to maximize facial nerve recovery. 1

Recommended Steroid Regimen

• Prednisolone 50 mg daily for 10 days (no taper) 1, 2
• OR
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 3

Timing of Treatment

• Steroids must be initiated within 72 hours of symptom onset for maximum effectiveness 1, 4
• Treatment started within this window shows significantly better outcomes (83% recovery at 3 months with prednisolone vs 63.6% with placebo) 1
• Starting treatment after 72 hours provides minimal benefit and exposes patients to medication risks 4

Evidence for Effectiveness

• Strong evidence supports early corticosteroid use, with 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1, 5
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 5
• Single-dose intravenous methylprednisolone (500 mg) has shown similar effectiveness to oral prednisolone in some studies 6

Special Populations Considerations

Children

• Children have higher rates of spontaneous recovery than adults 1, 7
• Evidence for steroid use in children is less conclusive 1, 7
• A recent randomized controlled trial showed no significant improvement with prednisolone in children at 1 month, though the study was underpowered 7

Pregnant Women

• Treatment should be administered within 72 hours of symptom onset 1
• Careful individualized assessment of benefits and risks is necessary 1

Follow-up and Monitoring

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1
• Complete recovery typically occurs within 3-4 months for most patients 1
• Patients should be reassessed or referred to a facial nerve specialist if they have:
  • New or worsening neurologic findings at any point 1
  • Ocular symptoms developing at any point 1
  • Incomplete facial recovery 3 months after initial symptom onset 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours significantly reduces effectiveness 4
• Using antiviral therapy alone is ineffective and not recommended 1, 2
• Failing to provide adequate eye protection for patients with impaired eye closure can lead to corneal damage 1
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1

Additional Considerations

• Combination therapy with antivirals (valacyclovir or aciclovir) may be considered but provides only marginal additional benefit 1, 8
• Eye protection is essential for patients with impaired eye closure to prevent corneal damage 1