What are the dosing recommendations for corticosteroids (e.g. prednisone) and antivirals (e.g. valacyclovir, acyclovir) in the treatment of Bell’s palsy?

Steroid and Antiviral Dosing for Bell's Palsy

For Bell's palsy, prescribe 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; antivirals may be added but provide minimal additional benefit and should never be used alone. 1

Corticosteroid Dosing (First-Line Treatment)

Prednisone regimen:

• 60 mg orally daily for 5 days, then taper over 5 days 1

Alternative prednisolone regimen:

• 50 mg orally daily for 10 days (no taper) 1

Critical timing requirement:

• Must initiate within 72 hours of symptom onset for proven efficacy 1, 2
• Treatment started after 72 hours has no high-quality evidence supporting benefit 2
• Recovery rates with early steroids: 83% at 3 months versus 63.6% with placebo; 94.4% at 9 months versus 81.6% with placebo 1

Antiviral Dosing (Optional Add-On Only)

Valacyclovir (preferred):

• 1 gram orally three times daily for 7 days 3

Acyclovir (alternative):

• 400 mg orally five times daily for 10 days 1, 3

Critical restrictions:

• Antivirals must be combined with corticosteroids—never prescribe as monotherapy 1, 3
• Added benefit is minimal; combination therapy shows 96.5% complete recovery versus 89.7% with steroids alone 1
• Primary benefit may be reduction in long-term sequelae (synkinesis, crocodile tears) rather than improved facial recovery 4

Pediatric Dosing Considerations

Prednisolone for children:

• 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 1
• Evidence for steroid benefit in children is less conclusive than in adults 1
• Children have better spontaneous recovery rates (up to 94%) than adults 1, 3
• Decision should involve substantial caregiver participation given uncertain benefit-harm ratio 1

Special Population: Pregnancy

• Treat with standard corticosteroid regimens within 72 hours 1
• Pregnant women have excellent recovery rates (up to 90%) 3
• Combination therapy with antivirals may be considered on individualized basis 1

Common Pitfalls to Avoid

Timing errors:

• Starting steroids beyond 72 hours provides minimal benefit and exposes patients to medication risks without proven efficacy 2
• The 100% recovery rate seen with treatment within 3 days drops to 84.2% when started at 4+ days 5

Antiviral misuse:

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 3, 4
• Delaying appropriate corticosteroid treatment while prescribing antivirals alone is a critical error 1

Inadequate eye protection:

• Regardless of medication timing, implement aggressive eye protection immediately for impaired eye closure 1, 2
• Use lubricating drops every 1-2 hours while awake, ophthalmic ointment at bedtime, and consider eye taping/patching 1

When Presenting After 72 Hours

If a patient presents on day 5 or later:

• Do not initiate corticosteroids—no evidence supports benefit after the 72-hour window 2
• Focus on eye protection measures to prevent corneal damage 2
• Reassure that 70% with complete paralysis and 94% with incomplete paralysis recover spontaneously within 6 months 2
• Monitor for recovery and refer if incomplete recovery persists at 3 months 2