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

Steroid Treatment for Bell's Palsy

Primary Recommendation

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, 2

This recommendation is based on strong evidence from the American Academy of Otolaryngology-Head and Neck Surgery guidelines, which demonstrate 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo. 2, 3

Critical Timing Window

The 72-hour window is absolute and non-negotiable:

• Steroids are only effective when initiated within 72 hours of symptom onset 1, 2
• Clinical trials demonstrating benefit specifically enrolled patients within this timeframe 1
• Starting treatment beyond 72 hours provides minimal benefit and exposes patients to medication risks without clear evidence of efficacy 1
• If a patient presents at day 5 or later, do not prescribe steroids - focus instead on eye protection and monitoring 1

Treatment Algorithm by Presentation Time

Within 24 hours of onset:

• Initiate prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with 5-day taper 2
• Consider adding antiviral therapy (valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days) as combination therapy may reduce synkinesis rates 4
• The benefit of combination therapy is small (96.5% recovery versus 89.7% with steroids alone) but risks are minimal 2

24-72 hours after onset:

• Same steroid regimen as above 2
• Combination therapy remains an option 2

Beyond 72 hours:

• Do not initiate steroids 1
• Focus on eye protection measures 1
• Monitor for recovery and refer if incomplete recovery at 3 months 1

Mandatory Eye Protection (All Patients)

Implement immediately for any patient with impaired eye closure, regardless of steroid eligibility:

• Lubricating ophthalmic drops frequently throughout the day 1, 2
• Ophthalmic ointments at night for moisture retention 1, 2
• Eye patching or taping (with careful instruction to avoid corneal abrasion) 1, 2
• Sunglasses for outdoor protection 1, 2
• Refer to ophthalmology if severe impairment or persistent symptoms 2

Special Populations

Pregnant women:

• Treat with oral corticosteroids within 72 hours using the same regimen 2
• The guidelines recommend treatment on an individualized basis, but given the strong evidence for benefit and the safety profile of short-term corticosteroids, treatment should be offered 2

Children:

• Children have better prognosis with up to 90% spontaneous recovery 4
• Evidence for steroid benefit in children is less conclusive 2
• Consider oral steroids on a case-by-case basis with caregiver involvement 2

Patients 16 years and older:

• Strong recommendation for oral corticosteroids within 72 hours 2

What NOT to Do

Never prescribe antiviral monotherapy:

• Acyclovir or valacyclovir alone is ineffective and should not be prescribed 1, 2, 3, 5
• Antivirals may only be considered in combination with steroids 2

Do not order routine testing:

• Laboratory testing and diagnostic imaging are NOT recommended for typical Bell's palsy diagnosis 2
• MRI with and without contrast is reserved for atypical presentations (bilateral weakness, recurrent paralysis on same side, isolated branch paralysis, other cranial nerve involvement, or no recovery after 3 months) 2

Follow-Up and Referral Triggers

Mandatory reassessment or specialist referral for:

• Incomplete facial recovery at 3 months after symptom onset 1, 2
• New or worsening neurologic findings at any point 1, 2
• Development of ocular symptoms at any point 1, 2

Natural History Context

Understanding prognosis helps frame treatment decisions:

• Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment 1
• Patients with incomplete paralysis have up to 94% recovery rates 1
• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 2
• 30% may experience permanent facial weakness with muscle contractures 2

Common Pitfalls to Avoid

• Starting steroids beyond 72 hours - this is the most common error and provides no proven benefit while exposing patients to medication risks 1
• Prescribing antivirals alone - this is ineffective and not recommended 1, 2
• Failing to provide adequate eye protection - this can lead to permanent corneal damage in patients with impaired eye closure 1, 2
• Not referring patients with incomplete recovery at 3 months - these patients need specialist evaluation for potential reconstructive procedures 2