Corticosteroid Protocol for Acute Bell's Palsy
Prescribe oral corticosteroids within 72 hours of symptom onset using either prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper. 1
Timing is Critical
The 72-hour window is non-negotiable for steroid efficacy. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation for oral steroids only when initiated within this timeframe. 1
Treatment after 72 hours has unclear benefit and is not supported by high-quality evidence. 1, 2 If a patient presents on day 5 or later, steroids should generally not be initiated as the risk-benefit ratio becomes unfavorable. 2
The evidence supporting steroid use comes from two landmark trials (Sullivan et al. with 551 patients and Engstrom et al. with 829 patients) that specifically enrolled patients within 72 hours, showing 83% recovery at 3 months with prednisolone versus 63.6% with placebo (P < .001). 1
Specific Dosing Regimens
Two evidence-based options exist: 1, 3
- Option 1: Prednisolone 50 mg orally daily for 10 days (no taper)
- Option 2: Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over the next 5 days
Both regimens are supported by randomized controlled trials and are equally acceptable. 1 The key is maintaining at least 5 days at high dose. 1
Age Considerations
For children under 16, evidence is limited as they were excluded from most treatment trials, though children generally have better spontaneous recovery rates (up to 90%) than adults. 3, 4
Combination Therapy with Antivirals
Antivirals alone are ineffective and should never be prescribed as monotherapy. 3, 4
Combination therapy (corticosteroids + antivirals) may be offered as an option within 72 hours, with some evidence suggesting higher complete recovery rates (96.5% versus 89.7% with steroids alone). 3
If adding antivirals, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days. 4
The benefit of adding antivirals is modest and of borderline statistical significance (RR 0.75,95% CI 0.56-1.00, P = .05). 5
Essential Concurrent Management
Eye protection is mandatory for patients with impaired eye closure: 2, 3
- Lubricating ophthalmic drops during the day
- Ophthalmic ointments at night
- Consider moisture chambers, eye patching/taping, and sunglasses
- Failure to provide adequate eye protection can lead to corneal damage and permanent vision loss 2, 3
Follow-Up and Referral Criteria
Reassess or refer to a facial nerve specialist if: 1, 3
- New or worsening neurologic findings develop at any point
- Ocular symptoms develop at any point
- Incomplete facial recovery persists 3 months after initial symptom onset
Common Pitfalls to Avoid
Starting steroids beyond 72 hours: This provides minimal benefit and exposes patients to medication risks without evidence of efficacy. 2
Using antivirals alone: This is completely ineffective and wastes resources. 3, 4
Routine imaging or laboratory testing: Not required for typical Bell's palsy presentations. 3 Imaging is only indicated for atypical features (bilateral paralysis, isolated branch involvement, other cranial nerve involvement, trauma history, or failure to recover after 3 months). 1
Inadequate eye protection: This can result in corneal ulceration and permanent vision loss in patients with lagophthalmos. 2, 3
Emerging Evidence on High-Dose Steroids
Recent meta-analysis suggests high-dose corticosteroids (≥80 mg daily) may provide superior outcomes compared to standard doses (40-60 mg), with significantly decreased nonrecovery at 6 months (OR 0.17,95% CI 0.05-0.56, P = .004). 6 However, this evidence has serious risk of bias, and current guidelines still recommend standard dosing of 50-60 mg daily. 1, 3 Until more robust trials are completed, standard dosing remains the evidence-based recommendation.
Natural History Context
Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment, and patients with incomplete paralysis have recovery rates up to 94%. 2 Most patients begin showing recovery within 2-3 weeks. 2 This favorable natural history underscores why treatment must be initiated early when it can meaningfully improve these already good baseline outcomes.