Duration of Oral Prednisolone 60 mg Daily for Acute Idiopathic Facial Palsy
For acute idiopathic facial palsy (Bell's palsy), oral prednisolone 60 mg once daily should be given for 5 days followed by a 5-day taper, or alternatively 50 mg daily for 10 days straight, with treatment initiated within 72 hours of symptom onset. 1
Standard Treatment Regimens
The American Academy of Otolaryngology-Head and Neck Surgery provides two equivalent evidence-based options for corticosteroid dosing:
Option 1: Short Course with Taper
- Prednisone/prednisolone 60 mg once daily for 5 days
- Followed by 5-day taper (typically decreasing by 10 mg per day: 50 mg, 40 mg, 30 mg, 20 mg, 10 mg)
- Total duration: 10 days 1, 2
Option 2: Fixed Dose Course
Both regimens achieve equivalent outcomes, with 83% recovery at 3 months versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo. 1, 3
Critical Timing Requirements
Treatment MUST be initiated within 72 hours of symptom onset to be effective. 1, 3
- Starting steroids beyond the 72-hour window provides no proven benefit and exposes patients to medication risks without efficacy 4, 1
- The 72-hour window exists because early corticosteroid treatment reduces facial nerve inflammation before permanent damage occurs 4
- Most patients begin showing recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months 1, 3
Administration Details
- Administer as a single daily dose, not divided doses, to optimize therapeutic effect 5
- Maximum dose should not exceed 60 mg daily 4
- Morning dosing is preferred to align with natural cortisol rhythm 1
Common Pitfalls to Avoid
Methylprednisolone Dose Packs Are Inadequate
Never use standard methylprednisolone dose packs for Bell's palsy. They provide only 84-105 mg prednisone equivalent over 6 days, which is grossly inadequate compared to the required 540 mg over 10-14 days. 4, 1
Delayed Treatment
Initiating steroids beyond 72 hours provides minimal benefit and should be avoided unless there are exceptional circumstances. 4, 1
Antiviral Monotherapy
Antiviral agents (acyclovir, valacyclovir) should NEVER be prescribed alone for Bell's palsy—they are ineffective as monotherapy. 1, 6 They may be added to corticosteroids in severe cases, but the added benefit is minimal. 1
Essential Concurrent Management
Eye Protection (Mandatory)
Implement aggressive eye protection immediately for any patient with impaired eye closure: 1, 3
- Lubricating ophthalmic drops every 1-2 hours while awake
- Ophthalmic ointment at bedtime
- Eye patching or taping at night (with careful instruction to avoid corneal abrasion)
- Sunglasses outdoors
- Immediate ophthalmology referral for severe impairment or persistent lagophthalmos
Follow-Up Requirements
- Mandatory reassessment or specialist referral at 3 months if incomplete recovery 1, 3
- Immediate referral for new or worsening neurologic findings at any point 1
- Urgent ophthalmology referral for development of ocular symptoms 1
Special Populations
Children
Evidence for steroid benefit in children is less conclusive than in adults, though children have better spontaneous recovery rates (up to 94%). 1 Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper, with substantial caregiver involvement in decision-making. 1, 7
Diabetic Patients
Diabetes is NOT a contraindication to corticosteroid therapy. 1 The therapeutic benefit outweighs the risk of temporary hyperglycemia. Monitor capillary blood glucose every 2-4 hours during the first few days and proactively adjust diabetes medications. 1
Pregnant Women
Treat with oral corticosteroids within 72 hours using the same regimens, with individualized assessment of benefits and risks. 1