What is the recommended steroid treatment regimen for a patient with Bell's palsy?

Steroid Administration in Bell's Palsy

For Bell's palsy, prescribe oral prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper, but ONLY if initiated within 72 hours of symptom onset. 1, 2

Critical Timing Window

• Treatment must begin within 72 hours of symptom onset to achieve meaningful benefit—this is a hard cutoff based on all clinical trial evidence 1, 2
• Starting steroids after 72 hours provides minimal to no benefit and unnecessarily exposes patients to medication risks 1
• Approximately half of patients can initiate treatment within 24 hours, one-third within 24-48 hours, and the remainder within 48-72 hours 3

Specific Dosing Regimens

Option 1 (Preferred for simplicity):

• Prednisolone 50 mg orally once daily for 10 days (no taper needed) 2, 3

Option 2:

• Prednisone 60 mg orally once daily for 5 days, then taper over 5 days 2, 4

Pediatric dosing (if treating children):

• Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by 5-day taper 2
• Note: Evidence for steroid benefit in children is less conclusive than in adults, requiring shared decision-making with caregivers 2

Evidence Supporting This Approach

• The landmark BELLS trial demonstrated 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (absolute benefit of 19.4%, NNT = 6) 3
• At 9 months, recovery rates improved to 94.4% with prednisolone versus 81.6% without (absolute benefit of 12.8%, NNT = 8) 3
• These results are only applicable when treatment starts within 72 hours, as all efficacy trials specifically enrolled patients within this window 1, 2

Route of Administration: Oral vs. Intravenous

• Oral steroids are the standard of care and should be used in routine practice 2, 4
• IV methylprednisolone may provide faster recovery to grade 1 at 1 month compared to oral prednisolone, particularly for severe (grade 4) paralysis, but shows no difference at 3 months 5
• The added complexity and cost of IV administration is not justified given equivalent long-term outcomes 5
• Reserve IV steroids for patients unable to take oral medications 5

What NOT to Do

• Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate treatment 1, 2, 4
• Do not restart or extend corticosteroids beyond the initial 10-day course, as evidence only supports the initial treatment window 6
• Avoid using standard methylprednisolone dose packs, which provide only 105 mg prednisone equivalent over 6 days versus the required 540 mg over 14 days—this represents significant underdosing 2

Combination Therapy with Antivirals (Optional)

• Antivirals may be added to steroids but provide minimal additional benefit 2, 4
• If choosing combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 2, 4
• The BELLS trial showed no significant benefit from adding aciclovir to prednisolone (79.7% recovery with combination vs 86.3% with prednisolone alone at 3 months) 3
• Some evidence suggests combination therapy may reduce synkinesis rates, but this benefit is small and risks are minimal 2, 4

Essential Concurrent Management

Eye protection is mandatory for all patients with impaired eye closure:

• Lubricating drops every 1-2 hours while awake 2, 6
• Ophthalmic ointment at bedtime 2, 6
• Eye taping or patching at night (with careful instruction to avoid corneal abrasion) 2
• Sunglasses outdoors 2
• Urgent ophthalmology referral if complete inability to close eye or signs of corneal damage 2

Prognostic Factors Affecting Treatment Response

Poor prognostic indicators requiring closer monitoring:

• Treatment delay beyond 7 days (RR = 18.87 for poor outcome) 7
• Severe facial paralysis at presentation (RR = 5.01) 7
• Hearing defect (RR = 3.01) 7
• History of recurrence (RR = 3.75) 7

Follow-Up Algorithm

• Week 1-2: Assess recovery progress, reinforce eye protection, identify complications 2
• Week 2-3: Most patients begin showing recovery signs 1, 6
• 3 months: Mandatory reassessment—refer to facial nerve specialist if incomplete recovery 1, 2, 6
• Immediate referral triggers: New/worsening neurologic findings, ocular symptoms, or progressive weakness beyond 3 weeks 2, 6

Common Pitfalls

• Treating patients who present after 72 hours—this exposes them to steroid risks without proven benefit 1
• Using antiviral monotherapy instead of steroids 1, 2
• Inadequate eye protection leading to corneal damage 1, 2
• Failing to refer patients with incomplete recovery at 3 months 1, 2
• Underdosing steroids by using standard methylprednisolone dose packs 2