Prednisone Dose for Bell's Palsy
For adults with Bell's palsy, prescribe prednisone 60 mg orally once daily for 5 days, followed by a 5-day taper (reducing by 10 mg every day), initiated within 72 hours of symptom onset. 1
Recommended Dosing Regimens
The American Academy of Otolaryngology-Head and Neck Surgery provides two equivalent evidence-based options for corticosteroid treatment 1:
- Prednisone 60 mg daily for 5 days followed by a 5-day taper (10 mg reduction every day) 1
- Prednisolone 50 mg daily for 10 days (alternative regimen) 1
Both regimens demonstrate strong efficacy, with 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 1, 2. The number needed to treat is 6 at 3 months and 8 at 9 months 2.
Critical Timing Window
Treatment must be initiated within 72 hours of symptom onset to be effective. 1, 3 After this window:
- No high-quality evidence supports benefit of corticosteroids started beyond 72 hours 3
- Clinical trials demonstrating efficacy specifically enrolled patients within the 72-hour window 3
- Starting treatment at day 5 or later provides minimal benefit and exposes patients to medication risks without proven advantage 3
Dosing Rationale and Equivalencies
The 60 mg prednisone dose is based on maximum adrenal cortisol output during stress (200-300 mg/day hydrocortisone equivalent) 4. Understanding steroid potency ratios is critical to avoid underdosing 4:
- Prednisone is 4 times more potent than hydrocortisone 4
- Methylprednisolone is 5 times more potent (equivalent dose: 48 mg) 4
- Dexamethasone is 25 times more potent (equivalent dose: 10 mg) 4
Common pitfall: The standard methylprednisolone dose pack (21 tablets of 4 mg over 6 days = 84 mg total) provides only 105 mg prednisone equivalent, compared to 540 mg over 14 days with proper dosing—this represents significant underdosing 4.
Weight-Based Dosing Considerations
For patients significantly below or above average weight, consider weight-based dosing 4, 5:
- 1 mg/kg/day prednisone (usual maximum 60 mg/day) 4, 5
- This ensures adequate dosing across body sizes while avoiding excessive doses in larger patients 4
Combination Therapy with Antivirals
Antivirals should never be prescribed as monotherapy—they are completely ineffective alone. 1, 3 However, combination therapy may be offered as an option 1:
- Valacyclovir 1000 mg three times daily for 7 days PLUS corticosteroids 5
- Acyclovir 400 mg five times daily for 10 days PLUS corticosteroids 1, 5
The added benefit of antivirals is small (96.5% complete recovery with combination versus 89.7% with steroids alone in some studies), but risks are minimal 1. The landmark BELLS trial showed no benefit from acyclovir, with recovery rates of 86.3% for prednisolone alone versus 79.7% for acyclovir-prednisolone combination at 3 months 2. Given conflicting evidence, corticosteroids alone remain the cornerstone of treatment 1.
Special Populations
Pediatric Patients
- Evidence for corticosteroid benefit in children is inconclusive 1, 6
- Children have better prognosis with 80-90% spontaneous recovery rates 6
- If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5-10 days followed by 5-day taper 6
- Engage caregivers in shared decision-making, explaining that benefit remains unproven in children 6
Pregnant Women
- Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
- Same dosing regimen as non-pregnant adults 1
- Eye protection measures are essential and safe in pregnancy 1
Mandatory Eye Protection Protocol
All patients with impaired eye closure require immediate aggressive eye protection to prevent corneal damage, regardless of whether corticosteroids are prescribed 1, 3:
- Lubricating ophthalmic drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime for sustained moisture retention 1
- Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 1
- Sunglasses outdoors for protection against wind and particles 1
- Urgent ophthalmology referral for severe impairment or signs of corneal exposure 1
Follow-Up and Referral Triggers
Mandatory reassessment or specialist referral is required for 1, 3:
- Incomplete facial recovery at 3 months after symptom onset 1
- New or worsening neurologic findings at any point 1
- Development of ocular symptoms at any point 1
- Progressive weakness beyond 3 weeks (suggests alternative diagnosis) 1
High-Dose Corticosteroid Controversy
Some evidence suggests high-dose corticosteroids (initial prednisolone 100-200 mg daily) may reduce non-recovery rates compared to standard doses (50-60 mg) 7. However, current guidelines recommend standard dosing (prednisone 60 mg or prednisolone 50 mg) as the evidence-based approach 1, as high-dose regimens lack standardization and prospective validation 7.