What medications and dosages are recommended for a 48-year-old patient with Bell's palsy?

Medications and Dosages for Bell's Palsy in a 48-Year-Old Patient

Prescribe oral prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper (10 mg reduction per day), initiated within 72 hours of symptom onset. 1

Primary Pharmacologic Treatment

Corticosteroids are the only proven effective treatment for Bell's palsy and must be started within 72 hours of symptom onset. 1, 2

Corticosteroid Regimen Options:

• Prednisolone 50 mg orally once daily for 10 days (preferred regimen) 1
• Prednisone 60 mg orally once daily for 5 days, then taper by 10 mg daily for 5 additional days (total 10 days) 1, 3

Evidence Supporting Corticosteroids:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 4
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 4
• Number needed to treat is 6 at 3 months and 8 at 9 months 4

Optional Combination Therapy

Antiviral therapy may be added to corticosteroids (not as monotherapy) within 72 hours of symptom onset, though the added benefit is minimal. 1, 2

Antiviral Options (ONLY in combination with corticosteroids):

• Valacyclovir 1000 mg orally three times daily for 7 days 2, 3
• Acyclovir 400 mg orally five times daily for 10 days 1, 2

Critical Caveat:

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 5
• The benefit of adding antivirals to steroids is small (combination therapy shows 96.5% recovery versus 89.7% with steroids alone), but risks are minimal 1

Essential Supportive Eye Care Medications

All patients with impaired eye closure require aggressive eye protection to prevent corneal damage. 1

Eye Protection Regimen:

• Lubricating ophthalmic drops (preservative-free artificial tears): Apply every 1-2 hours while awake 1, 6
• Ophthalmic ointment (e.g., erythromycin or bacitracin): Apply at bedtime for sustained moisture retention 1, 6
• Sunglasses: Wear outdoors for protection against wind and foreign particles 1
• Eye patching or taping at night (with careful instruction to avoid corneal abrasion) 1

When to Refer to Ophthalmology:

• Severe impairment with complete inability to close the eye 1
• Any signs of corneal exposure or damage 1
• Development of eye pain, vision changes, redness, or discharge 1

Critical Timing and Pitfalls to Avoid

Treatment Window:

• Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence of benefit after this window 1, 7
• One-half of patients should initiate treatment within 24 hours, one-third within 24-48 hours, and the remainder within 48-72 hours 4

Common Prescribing Errors:

• Avoid methylprednisolone dose packs—they provide only 84 mg total over 6 days, which is grossly inadequate compared to 540 mg prednisone over 14 days 7
• Never prescribe antiviral monotherapy—it delays appropriate corticosteroid treatment and is completely ineffective 1, 5
• Do not restart or extend corticosteroids beyond the initial 10-day course 6

Follow-Up and Reassessment Triggers

Mandatory reassessment or specialist referral is required at 3 months if incomplete facial recovery persists. 1, 6

Red Flags Requiring Immediate Referral:

• New or worsening neurologic findings at any point 1, 6
• Development of ocular symptoms at any point 1, 6
• Incomplete facial recovery at 3 months after symptom onset 1, 6

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks of symptom onset 1, 6
• Complete recovery typically occurs within 3-4 months 1, 6
• Approximately 70% of patients with complete paralysis recover fully within 6 months 1
• Patients with incomplete paralysis have recovery rates up to 94% 1