What is the recommended corticosteroid (e.g. prednisone) tapering regimen for Bell's palsy?

Corticosteroid Tapering Regimen for Bell's Palsy

Recommended Steroid Regimen

For Bell's palsy patients 16 years and older, prescribe either prednisolone 50 mg daily for 10 days (no taper) OR 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

Treatment Algorithm

Timing-Based Approach

• Within 72 hours of onset: Initiate corticosteroids immediately using one of the two regimens above 1, 2

  • Evidence shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1
  • Recovery improves to 94.4% at 9 months with prednisolone versus 81.6% with placebo 1

• Beyond 72 hours (Day 4-5 or later): Do NOT initiate corticosteroids 2

  • No high-quality evidence supports benefit after the 72-hour window 2
  • Clinical trials demonstrating efficacy specifically enrolled patients within 72 hours 2
  • Focus instead on eye protection and supportive care 2

Specific Dosing Regimens

Option 1 (Preferred for simplicity):

• Prednisolone 50 mg orally once daily for 10 consecutive days 1
• No taper required 1

Option 2:

• Prednisone 60 mg orally once daily for 5 days 1
• Then taper: 50 mg (day 6), 40 mg (day 7), 30 mg (day 8), 20 mg (day 9), 10 mg (day 10) 1

Special Populations

Children

• Consider oral corticosteroids on an individualized basis with caregiver involvement 1
• Dosing: Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 3
• Evidence for benefit in children is less conclusive than in adults, though children have better spontaneous recovery rates (up to 90%) 1, 4

Pregnant Women

• Treat with oral corticosteroids within 72 hours using standard adult dosing 1
• Requires individualized assessment of benefits and risks 1
• Eye protection measures are essential and safe in pregnancy 1

Critical Pitfalls to Avoid

• Never start corticosteroids beyond 72 hours: Treatment after this window provides minimal benefit and exposes patients to medication risks without proven efficacy 2

• Never prescribe antiviral monotherapy: Antivirals alone are ineffective and should never be used without corticosteroids 1, 2, 4

• Never extend or restart corticosteroids: Do not continue beyond the initial 10-day course, even if pain or weakness persists at 2 weeks 3

• Never delay treatment within the 72-hour window: Every hour counts for maximizing nerve recovery 1, 2

Combination Therapy Consideration

• 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 1, 4
• Combination therapy shows slightly higher complete recovery rates (96.5%) compared to steroids alone (89.7%), though benefit is small 1
• Combination therapy may reduce synkinesis rates 4

Essential Concurrent Management

Eye Protection (Mandatory for all patients with impaired eye closure)

• Daytime: Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Nighttime: Ophthalmic ointment at bedtime 1, 2
• Outdoor: Sunglasses for protection against wind and particles 1, 2
• Severe cases: Eye taping/patching with proper instruction or moisture chambers 1, 2
• Urgent ophthalmology referral: If complete inability to close eye or signs of corneal damage 1

Follow-Up Requirements

• Reassess or refer to facial nerve specialist if incomplete recovery at 3 months 1, 2
• Immediate referral if new or worsening neurologic findings develop at any point 1, 2
• Immediate referral if ocular symptoms develop 1, 2