Prednisone Dosing for Bell's Palsy
For adults and adolescents 16 years and older with Bell's palsy, prescribe prednisone 60 mg once daily for 5 days, followed by a 5-day taper, initiated within 72 hours of symptom onset. 1, 2
Specific Dosing Regimens
You have two evidence-based options:
- Option 1 (Preferred): Prednisone 60 mg once daily for 5 days, then taper over 5 days 1, 2
- Option 2 (Alternative): Prednisolone 50 mg once daily for 10 days (no taper) 1, 2
Both regimens achieve excellent recovery rates: 83% at 3 months versus 63.6% with placebo, and 94.4% at 9 months versus 81.6% with placebo. 1, 2, 3
Critical Timing Window
- Initiate treatment within 72 hours of symptom onset - this is the window where corticosteroids provide maximum benefit 1, 2
- Treatment beyond 72 hours has unclear benefit and is not recommended 1, 2
- The 72-hour window exists because early corticosteroid treatment reduces facial nerve inflammation before permanent damage occurs 4
Administration Details
- Give as a single daily dose, not divided doses, to optimize therapeutic effect 4
- Maximum dose should not exceed 60 mg daily 4
- Administer in the morning to minimize sleep disturbance 2
Sample Taper Schedule (for 60 mg regimen)
- Days 1-5: Prednisone 60 mg once daily 1, 2
- Days 6-7: Prednisone 40 mg once daily 1
- Days 8-9: Prednisone 20 mg once daily 1
- Days 10: Prednisone 10 mg once daily 1
Critical Pitfall to Avoid
Never use methylprednisolone dose packs - they provide only 84 mg total over 6 days, which is grossly inadequate compared to 540 mg prednisone over 14 days for a 60-kg adult. 4 This is a common error that significantly undermines treatment efficacy.
Antiviral Therapy Considerations
- Do NOT prescribe antiviral monotherapy - it is ineffective and not recommended 1, 2, 3
- You may offer combination therapy (oral corticosteroid + antiviral) within 72 hours as an option, though the additional benefit is small 2, 5
- If adding an antiviral: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 5
Essential Concurrent Management
Implement aggressive eye protection immediately for any patient with impaired eye closure: 2, 4
- Lubricating ophthalmic drops every 1-2 hours while awake 2
- Ophthalmic ointment at bedtime 2
- Eye taping or patching at night (with careful instruction to avoid corneal abrasion) 2
- Sunglasses outdoors 2
- Urgent ophthalmology referral if severe impairment or complete inability to close the eye 2, 6
Special Populations
Children: Evidence for steroid benefit in children is inconclusive, as children have higher spontaneous recovery rates (up to 90%) than adults. 1, 2, 5 If treating, consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper, with substantial caregiver involvement in decision-making. 2
Pregnant women: Treat with oral corticosteroids within 72 hours using the same regimen, with individualized assessment of benefits and risks. 2
Follow-Up Requirements
- Mandatory reassessment or specialist referral at 3 months if incomplete recovery 2, 6
- Refer immediately for new or worsening neurologic findings at any point 2
- Refer immediately for development of ocular symptoms 2
- Most patients begin showing recovery within 2-3 weeks, with complete recovery typically within 3-4 months 2, 6