What is the role of prednisone in the treatment of Bell's palsy?

Prednisone in Bell's Palsy

Primary Treatment Recommendation

Prescribe oral prednisone (60 mg daily for 5 days followed by a 5-day taper) or prednisolone (50 mg daily for 10 days) within 72 hours of symptom onset for all Bell's palsy patients aged 16 years and older. 1, 2

This is a strong recommendation based on high-quality randomized controlled trials demonstrating significant improvement in facial nerve recovery. 1

Evidence Supporting Corticosteroid Use

The evidence for prednisone/prednisolone in Bell's palsy is robust:

• 83% of patients treated with prednisolone recovered facial function at 3 months compared to 63.6% with placebo (P<0.001) 1, 3
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo (P<0.001) 1, 3
• Early deterioration occurs in 28% of patients, and prednisolone significantly improves outcomes in this group (62% complete recovery versus 31% without treatment) 4

Critical Timing Window

Treatment MUST be initiated within 72 hours of symptom onset. 1, 2, 5

• The benefit of treatment after 72 hours is unclear and not supported by high-quality evidence 5
• All major clinical trials demonstrating efficacy specifically enrolled patients within this 72-hour window 1, 3
• If a patient presents at day 5 or later, do NOT start corticosteroids - focus instead on eye protection and monitoring for recovery 5

Dosing Regimens

Two evidence-based regimens are equally acceptable: 1, 2

• Prednisone 60 mg daily for 5 days, then taper over 5 days 1
• Prednisolone 50 mg daily for 10 days 1

Both regimens were used in the pivotal randomized controlled trials and showed similar efficacy. 1

Special Populations

Children (Under 16 Years)

The evidence does NOT support routine corticosteroid use in children. 2, 6

• Children have spontaneous recovery rates up to 90%, significantly higher than adults 2, 7
• A 2022 randomized controlled trial in children showed no benefit: 49% recovery with prednisolone versus 57% with placebo at 1 month (not statistically significant) 8
• Consider corticosteroids only for severe or complete paralysis in children, with substantial caregiver involvement in shared decision-making 2, 6
• If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper 2

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours using individualized benefit-risk assessment. 2, 6

• Pregnant women can achieve recovery rates up to 90% 7
• The decision requires careful weighing of corticosteroid risks in pregnancy against the benefits of improved facial nerve recovery 2

Patients with Comorbidities

Consider individualized assessment for patients with: 6

• Diabetes mellitus (monitor glucose closely)
• Morbid obesity
• Previous steroid intolerance
• Active infections

However, do not withhold treatment in most cases - the short course of corticosteroids carries minimal risk compared to the benefit of improved facial nerve recovery. 1, 6

Antiviral Therapy Considerations

Do NOT prescribe antiviral therapy alone - it is ineffective. 1, 2, 6, 3

• Acyclovir alone showed 71.2% recovery versus 75.7% without acyclovir (not statistically significant, P=0.50) 3
• You may offer combination therapy (corticosteroid + antiviral) within 72 hours as an option, though the additional benefit is small 2, 6
• If using combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 7

Mandatory Eye Protection

Implement aggressive eye protection immediately for ALL patients with impaired eye closure, regardless of whether corticosteroids are prescribed. 2, 6

Eye Protection Protocol:

• Lubricating ophthalmic drops every 1-2 hours while awake 2, 6
• Ophthalmic ointment at bedtime 2, 6
• Eye patching or taping at night (with careful instruction to avoid corneal abrasion) 2, 6
• Sunglasses for outdoor protection 2, 6
• Moisture chambers using polyethylene covers for severe cases 2, 6

Urgent ophthalmology referral is required for: 2

• Complete inability to close the eye
• Signs of corneal exposure or damage
• Eye pain, vision changes, or increasing irritation

Follow-Up and Reassessment

Mandatory reassessment or specialist referral is required for: 2, 6

• Incomplete facial recovery at 3 months after symptom onset 2, 6
• New or worsening neurologic findings at any point 2, 6
• Development of ocular symptoms at any point 2, 6

Expected Recovery Timeline:

• Most patients begin showing recovery within 2-3 weeks 2, 5
• Complete recovery typically occurs within 3-4 months 2, 5
• Approximately 70% of patients with complete paralysis recover fully within 6 months 2, 5
• Patients with incomplete paralysis have recovery rates up to 94% 2, 5

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours - this significantly reduces or eliminates corticosteroid effectiveness 5, 6
• Using antiviral monotherapy - this is completely ineffective and wastes time 1, 2, 6
• Inadequate eye protection - this can lead to permanent corneal damage even if facial nerve recovery is complete 2, 6
• Failing to refer at 3 months for incomplete recovery - this delays access to reconstructive options and psychological support 2, 6
• Overtreating children with corticosteroids - pediatric data does not support the benefit seen in adults 2, 8
• Improper eye taping technique - patients must receive careful instruction to avoid corneal abrasion 2, 6

Therapies NOT Recommended

Do NOT offer the following treatments: 2, 6

• Antiviral monotherapy (ineffective) 1, 2, 6
• Surgical decompression (rarely indicated, no proven benefit) 2, 6
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 2
• Physical therapy as primary treatment (limited evidence, though may be beneficial in severe cases) 2, 7