What is the recommended dosage of prednisone (corticosteroid) for treating Bell's palsy?

Prednisone Dosing for Bell's Palsy

For Bell's palsy patients 16 years and older presenting within 72 hours of symptom onset, prescribe prednisone 60 mg daily for 5 days followed by a 5-day taper, or alternatively prednisolone 50 mg daily for 10 days. 1, 2

Critical Timing Window

• Treatment must be initiated within 72 hours of symptom onset to achieve meaningful benefit—this is a hard deadline, not a suggestion 1, 3, 2
• Patients treated within 24 hours achieve 66% complete recovery versus 51% without steroids 4
• Patients treated within 25-48 hours achieve 76% complete recovery versus 58% without steroids 4
• After 72 hours, steroid therapy provides minimal to no benefit and should not be initiated 3, 2

Specific Dosing Regimens

Option 1 (Preferred in U.S. practice):

• Prednisone 60 mg orally once daily for 5 days 2, 5
• Then taper: 40 mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 1 day 5

Option 2:

• Prednisolone 50 mg orally once daily for 10 days (no taper required) 1, 2, 6

Evidence Supporting This Approach

The landmark BELLS trial demonstrated that prednisolone treatment achieves:

• 83% complete recovery at 3 months versus 63.6% with placebo (NNT = 6) 6, 7
• 94.4% complete recovery at 9 months versus 81.6% with placebo (NNT = 8) 6, 7

Antiviral Therapy Considerations

• Never prescribe antiviral monotherapy—it is completely ineffective 1, 2, 5
• May consider adding valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to steroids, though benefit is marginal 1, 5
• Combination therapy shows slightly higher recovery rates (96.5% vs 89.7% with steroids alone) but this difference is small 2

Pediatric Dosing

For children with Bell's palsy:

• Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 2
• Important caveat: Evidence for steroid benefit in children is inconclusive, unlike in adults 1, 2
• Children have excellent prognosis with up to 90% spontaneous recovery rates 5
• Involve caregivers in shared decision-making given uncertain benefit-harm ratio 2

Prognostic Factors Affecting Treatment Response

Patients with poor prognostic indicators require particularly aggressive early treatment:

• Severe or complete facial paralysis at presentation (RR for poor outcome = 5.01) 8
• Treatment delay beyond 7 days (RR for poor outcome = 18.87) 8
• Hearing defect (RR for poor outcome = 3.01) 8
• History of recurrence (RR for poor outcome = 3.75) 8

Essential Concurrent Eye Protection

All patients with impaired eye closure require immediate eye protection, regardless of steroid therapy:

• Lubricating drops every 1-2 hours while awake 2
• Ophthalmic ointment at bedtime 2
• Eye taping or patching at night (with proper instruction to avoid corneal abrasion) 2
• Sunglasses outdoors 2
• Urgent ophthalmology referral if complete inability to close eye 2

Common Pitfalls to Avoid

• Starting steroids after 72 hours—this exposes patients to medication risks without benefit 3, 2
• Prescribing antivirals alone—completely ineffective 1, 2, 5
• Failing to provide adequate eye protection—can lead to permanent corneal damage 3, 2
• Not counseling patients that 70% with complete paralysis recover spontaneously within 6 months even without treatment 3, 2

Follow-Up Requirements

Mandatory reassessment or specialist referral for:

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