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

Steroid Treatment for Bell Palsy

For adults and adolescents ≥16 years with Bell palsy, 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

Critical Timing Window

• Treatment must begin within 72 hours of symptom onset to achieve meaningful benefit—this is a hard deadline, not a suggestion. 1, 2
• After 72 hours (Day 5 or later), corticosteroids provide minimal to no benefit and should not be initiated, as all clinical trials demonstrating efficacy specifically enrolled patients within this window. 2
• The 72-hour cutoff exists because early treatment reduces facial nerve inflammation before permanent damage occurs. 2

Evidence Supporting Steroid Use

• Strong evidence from high-quality trials shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo. 1
• Even without treatment, approximately 70% of patients with complete paralysis recover fully within 6 months, but steroids significantly improve these odds. 1, 2
• Patients with incomplete paralysis have excellent prognosis with up to 94% recovery rates. 1

Dosing Regimens

Standard-dose options (choose one): 1

• Prednisolone 50 mg orally daily for 10 days (no taper needed)
• Prednisone 60 mg orally daily for 5 days, then taper over 5 days

High-dose consideration for severe cases:

• Emerging evidence suggests high-dose corticosteroids (≥80-200 mg prednisolone equivalent daily) may reduce non-recovery rates compared to standard dosing (OR 0.17-0.42), though this remains investigational and is not yet guideline-recommended. 3, 4
• IV methylprednisolone may provide faster recovery to grade 1 at 1 month compared to oral prednisolone in severe cases (grade 4), but shows no difference at 3 months. 5
• For standard practice, stick with guideline-recommended standard doses unless participating in a clinical trial or consulting a specialist. 1

Antiviral Therapy: Limited Role

• Never prescribe antivirals alone—they are completely ineffective as monotherapy. 1, 2, 6
• Combination therapy (oral steroid + valacyclovir 1g three times daily for 7 days OR acyclovir 400mg five times daily for 10 days) may be offered as an option within 72 hours, but the added benefit is minimal. 1, 6
• The primary treatment remains corticosteroids; antivirals are supplementary at best. 1

Special Populations

Children (<16 years): 1, 7

• Children have better prognosis than adults with up to 90% spontaneous recovery rates. 6
• A 2022 high-quality RCT (Class I evidence) showed prednisolone does not significantly improve recovery at 1 month in children (49% vs 57% placebo, p=NS). 7
• Steroid benefit in children is unproven—involve caregivers in shared decision-making and explain most children recover without treatment. 1
• If treating, use prednisolone 1 mg/kg/day (max 50-60 mg) for 5 days with 5-day taper, only within 72 hours of onset. 1

Pregnant women: 1

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment.
• Pregnancy does not contraindicate steroid use for Bell palsy.
• Recovery rates in pregnancy approach 90%. 6

Essential Eye Protection (All Patients)

For impaired eye closure, implement immediately: 1, 2

• Lubricating drops every 1-2 hours while awake
• Ophthalmic ointment at bedtime for sustained moisture
• Eye taping/patching at night (with careful instruction to avoid corneal abrasion)
• Sunglasses outdoors
• Moisture chambers for severe cases

Urgent ophthalmology referral if: 1

• Complete inability to close eye
• Eye pain, vision changes, or signs of corneal exposure

Common Pitfalls to Avoid

• Starting steroids after 72 hours—this exposes patients to medication risks without proven benefit. 2
• Prescribing antivirals alone—completely ineffective and delays appropriate treatment. 1, 2
• Underdosing with methylprednisolone dose packs—standard dose packs provide only 105 mg prednisone equivalent versus the required 540 mg over 14 days. 1
• Neglecting eye protection—can lead to permanent corneal damage even if facial recovery is good. 1, 2

Follow-Up and Referral Triggers

Mandatory reassessment or specialist referral if: 1, 2

• Incomplete facial recovery at 3 months
• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point
• Progressive weakness beyond 3 weeks (suggests alternative diagnosis)

Expected recovery timeline: 1

• Most patients show improvement within 2-3 weeks
• Complete recovery typically occurs within 3-4 months
• 30% may have permanent mild weakness

What NOT to Do

• Do not order routine labs or imaging for typical Bell palsy presentation. 1
• Do not prescribe physical therapy routinely—evidence shows no benefit over spontaneous recovery. 1
• Do not perform surgical decompression except in rare specialized circumstances. 1
• Do not restart or extend corticosteroids beyond the initial 10-day course. 8