Prednisone Tapering for Bell's Palsy
For Bell's palsy in adults ≥16 years, prescribe prednisone 60 mg daily for 5 days followed by a 5-day taper (reducing by 10 mg daily), initiated within 72 hours of symptom onset. 1
Recommended Dosing Regimens
The American Academy of Otolaryngology-Head and Neck Surgery provides two evidence-based options for corticosteroid treatment: 2, 1
Option 1 (Preferred for simplicity):
- Prednisolone 50 mg once daily for 10 days (no taper required) 1
Option 2 (Standard taper):
- Prednisone 60 mg daily for 5 days 1
- Then taper by 10 mg daily over the next 5 days:
- Days 6-7: 50 mg daily
- Days 8-9: 40 mg daily
- Days 10-11: 30 mg daily
- Days 12-13: 20 mg daily
- Days 14-15: 10 mg daily 3
Both regimens are equally effective, with 83% recovery at 3 months and 94.4% recovery at 9 months compared to 63.6% and 81.6% with placebo, respectively. 1
Critical Timing and Administration
- Initiate treatment within 72 hours of symptom onset - this is the therapeutic window where corticosteroids demonstrate proven benefit. 2, 1
- Treatment beyond 72 hours lacks evidence of efficacy and should not be initiated. 4, 5
- Administer as a single morning dose before 9 AM to minimize HPA axis suppression and align with natural cortisol rhythms. 6
- Take with food or milk to reduce gastric irritation. 6
Common Pitfalls to Avoid
Do NOT use methylprednisolone dose packs - these provide only 84 mg total over 6 days, which is grossly inadequate compared to the 540 mg total prednisone delivered over the recommended 10-14 day course. 5
Do NOT prescribe antiviral monotherapy alone - antivirals without corticosteroids are ineffective and strongly contraindicated. 2, 1
Do NOT restart or extend corticosteroids beyond the initial course - there is no evidence supporting retreatment or prolonged therapy, even if pain persists at 2 weeks. 4
Do NOT abruptly discontinue therapy - always complete the full taper to allow HPA axis recovery. 6
Combination Therapy Consideration
You may offer valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days in addition to corticosteroids within 72 hours of onset. 2, 1, 3 This combination may reduce synkinesis rates (96.5% complete recovery versus 89.7% with steroids alone), though the benefit is modest and risks are minimal. 1
Essential Concurrent Management
Implement aggressive eye protection immediately for any patient with impaired eye closure: 2, 1
- Lubricating drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime 1
- Eye taping or patching at night (with proper instruction to avoid corneal abrasion) 1
- Sunglasses outdoors 1
- Urgent ophthalmology referral if complete inability to close eye or signs of corneal exposure 1
Special Populations
Children: The benefit of corticosteroids in pediatric Bell's palsy remains uncertain despite favorable safety profiles. Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper only for severe/complete paralysis, with substantial caregiver involvement in shared decision-making. 1 Children have 90% spontaneous recovery rates without treatment. 3
Pregnant women: Treat with the standard corticosteroid regimen on an individualized basis, carefully weighing benefits and risks. 1
Follow-Up Requirements
Mandatory reassessment or specialist referral if: 2, 1
- New or worsening neurologic findings at any point
- Ocular symptoms develop at any point
- Incomplete facial recovery at 3 months after symptom onset
Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 1, 4 Approximately 70% of patients with complete paralysis and 94% with incomplete paralysis achieve full recovery. 1