What is the standard steroid treatment regimen for facial palsy?

Standard Steroid Treatment for Facial Palsy

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

Treatment Regimen Details

Primary Dosing Options

• Prednisolone 50 mg once daily for 10 days (preferred regimen) 1
• Prednisone 60 mg once daily for 5 days, then taper by 10 mg daily over 5 days 1, 2
• Alternative regimen: Prednisolone 25 mg twice daily for 10 days 3

Critical Timing Window

• Treatment MUST begin within 72 hours of symptom onset to maximize recovery potential 1, 4
• Initiating steroids beyond 72 hours provides minimal to no benefit 1, 4
• The evidence supporting steroid efficacy is specific to this early treatment window 1

Administration Guidelines

• Administer in the morning prior to 9 AM to align with maximal adrenal cortex activity 2
• Take with food or milk to reduce gastric irritation 2
• Consider antacids between meals when using large doses to prevent peptic ulcers 2

Evidence Supporting This Regimen

The steroid treatment demonstrates robust efficacy:

• 83% recovery at 3 months with prednisolone vs 63.6% with placebo (Number Needed to Treat = 10) 1, 3
• 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1
• Reduces risk of late sequelae including synkinesis, autonomic disturbances, and contractures 3

Special Population Considerations

Children (Under 16 Years)

• Evidence for steroid benefit in children is inconclusive 1, 5
• Children have better prognosis with higher spontaneous recovery rates (up to 90%) than adults 1, 6
• A 2022 randomized controlled trial showed no significant benefit from prednisolone in children 5
• If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 7
• Decision should involve substantial caregiver participation in shared decision-making 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 4
• Same dosing regimens as non-pregnant adults apply 1
• Eye protection measures are essential and safe in pregnancy 4

Iatrogenic/Traumatic Facial Palsy

• Use identical steroid regimens as for Bell's palsy 4
• Consider IV methylprednisolone 1 g/day for 5 days only for severe, refractory cases 4

Antiviral Therapy Considerations

Monotherapy: Never Appropriate

• Antiviral therapy alone should NEVER be prescribed for Bell's palsy 1, 7, 6, 8
• Antivirals as monotherapy are ineffective and delay appropriate corticosteroid treatment 1, 7

Combination Therapy: Optional with Minimal Benefit

• 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 1, 6
• Combination therapy shows small benefit: 96.5% complete recovery vs 89.7% with steroids alone 1
• Combination therapy probably reduces late sequelae (synkinesis, crocodile tears) compared to corticosteroids alone (RR 0.56,95% CI 0.36-0.87) 8
• Consider combination therapy for severe cases with intense pain or suspicion of herpes zoster sine herpete 3
• Mandatory for confirmed varicella-zoster virus infection 3

Essential Concurrent Management

Eye Protection (Critical)

• Implement immediately for any patient with impaired eye closure 1, 4
• Lubricating ophthalmic drops every 1-2 hours while awake 1, 7
• Ophthalmic ointment (dexpanthenol) at bedtime for sustained moisture 1, 3
• Eye patching or taping at night with careful instruction on proper technique 1, 7
• Sunglasses outdoors for protection against wind and particles 1, 7
• Urgent ophthalmology referral for severe impairment or complete inability to close eye 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness dramatically 1, 4
• Prescribing antivirals alone is ineffective and inappropriate 1, 7, 6
• Restarting or extending corticosteroids beyond the initial 10-day course has no evidence support 7
• Neglecting eye protection can lead to permanent corneal damage 1, 4
• Failing to refer at 3 months if incomplete recovery delays access to reconstructive options 1, 7

Follow-Up and Reassessment Triggers

Mandatory Reassessment or Specialist Referral

• Incomplete facial recovery at 3 months after symptom onset 1, 4, 7
• New or worsening neurologic findings at any point 1, 7
• Development of ocular symptoms at any point 1, 7

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks 1, 4, 7
• Complete recovery typically occurs within 3-4 months 1, 4
• Patients with incomplete paralysis: up to 94% recovery 1
• Patients with complete paralysis: 70% full recovery within 6 months 1, 4
• Approximately 30% may experience permanent facial weakness with contractures 1, 4