Should prednisone be started as soon as possible for Bell's (Bell's palsy) palsy, even at night?

Should Prednisone Be Started Immediately for Bell's Palsy, Even at Night?

Yes, prednisone should be started immediately upon diagnosis of Bell's palsy, even at night, as long as you are within 72 hours of symptom onset—the critical therapeutic window that determines treatment effectiveness. 1, 2

The 72-Hour Window Is Absolute

• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends oral corticosteroids only when initiated within 72 hours of symptom onset. 1, 2
• Treatment started beyond 72 hours provides minimal benefit and lacks high-quality evidence supporting its use. 1
• Every hour counts within this window—research demonstrates that patients treated within 24 hours had 66% complete recovery, those treated at 25-48 hours had 76% recovery, but those treated at 49-72 hours showed no significant benefit over placebo. 3

Why Immediate Treatment Matters More Than Timing of Day

• Early corticosteroid treatment reduces inflammation of the facial nerve before permanent damage occurs. 1
• The evidence supporting steroid efficacy (83% recovery at 3 months with prednisolone versus 63.6% with placebo) specifically enrolled patients within 72 hours, with treatment initiated as soon as possible after diagnosis. 1, 4, 5
• Delaying treatment to wait for morning administration wastes precious hours within the narrow therapeutic window and is not supported by guidelines. 1

Practical Dosing Considerations

• The recommended regimen is prednisone 60 mg daily for 5 days followed by a 5-day taper OR prednisolone 50 mg daily for 10 days. 1, 2
• While the FDA label notes that morning administration (before 9 AM) optimally aligns with circadian cortisol rhythms and minimizes HPA axis suppression, 6 this pharmacologic principle should not delay urgent treatment when diagnosed outside morning hours.
• For a short 10-day course in Bell's palsy, the timing of daily administration is far less critical than initiating treatment within the 72-hour window. 1, 2

Treatment Algorithm for Night Presentation

If diagnosed at night within 72 hours of symptom onset:

• Start prednisone immediately—do not wait until morning. 1, 2, 3
• Give the first dose at the time of diagnosis, regardless of hour. 3
• Subsequent daily doses can be taken in the morning to align with physiologic cortisol patterns. 6
• Advise taking with food or milk to reduce gastric irritation. 6

If diagnosed beyond 72 hours:

• Do not start steroids—the evidence does not support benefit and you expose patients to medication risks without proven efficacy. 1
• Focus instead on eye protection measures (lubricating drops, ointments, taping, moisture chambers). 1, 2

Critical Concurrent Measures

• Implement aggressive eye protection immediately for any patient with impaired eye closure, regardless of when steroids are started. 1, 2
• Use lubricating ophthalmic drops every 1-2 hours while awake. 2
• Apply ophthalmic ointment at bedtime for sustained moisture retention. 2
• Instruct on proper eye taping technique to prevent corneal abrasion. 2

Common Pitfalls to Avoid

• Waiting until morning to start treatment when diagnosed at night within the 72-hour window—this delays therapy during the critical period when nerve inflammation is progressing. 1, 3
• Starting steroids beyond 72 hours based on patient or provider preference—this lacks evidence and exposes patients to unnecessary medication risks. 1
• Prescribing antiviral monotherapy, which is ineffective and should never be used alone. 1, 2
• Failing to provide immediate eye protection while focusing solely on steroid therapy. 1, 2

Supporting Evidence Strength

• Multiple high-quality randomized controlled trials demonstrate significant benefit when steroids are initiated within 72 hours, with recovery rates of 94.4% at 9 months versus 81.6% without treatment (NNT = 8). 4, 5
• The benefit is most pronounced when treatment begins within 48 hours, with diminishing returns as you approach the 72-hour mark. 3
• Early deterioration occurs in 28% of patients within the first 11-17 days, and prednisolone given within 72 hours significantly reduces this progression (62% complete recovery versus 31% without treatment). 7