10-Day Oral Steroid Course is Sufficient for Bell's Palsy
A 10-day course of oral prednisolone (50 mg daily) is sufficient and should not be extended, as this is the evidence-based regimen that achieved 83% recovery at 3 months and 94.4% recovery at 9 months in landmark trials. 1
Evidence-Based Steroid Regimen
The American Academy of Otolaryngology-Head and Neck Surgery guidelines provide two equivalent options for corticosteroid treatment in Bell's palsy 1:
- Prednisolone 50 mg once daily for 10 days (preferred regimen) 1
- Prednisone 60 mg daily for 5 days followed by a 5-day taper (alternative) 1
Both regimens are supported by high-quality randomized controlled trials demonstrating significant improvement in facial nerve recovery when initiated within 72 hours of symptom onset 2, 3, 4.
Why Extension is Not Indicated
The 10-day duration is based on robust clinical trial evidence showing optimal outcomes without need for prolongation. The BELLS study (n=496) demonstrated that prednisolone 50 mg daily for 10 days achieved 83% complete recovery at 3 months versus 63.6% with placebo (NNT=6), and 94.4% recovery at 9 months versus 81.6% with placebo 2, 4. A separate multicenter trial (n=829) confirmed these findings, showing prednisolone significantly shortened time to complete recovery 3.
No evidence supports extending steroid treatment beyond 10 days, and doing so would expose patients to unnecessary medication risks without proven additional benefit. 1
Critical Treatment Principles
Timing is Everything
- Treatment must be initiated within 72 hours of symptom onset to achieve the documented benefits 1, 5
- Starting steroids after 72 hours provides minimal benefit and is not supported by high-quality evidence 5
- The 72-hour window exists because early corticosteroid treatment reduces facial nerve inflammation before permanent damage occurs 6, 5
Dosing Considerations
- Administer as a single daily dose, not divided doses, to optimize therapeutic effect 1
- Maximum daily dose should not exceed 60 mg 1
- For patients significantly below or above average weight, consider weight-based dosing of 1 mg/kg/day (maximum 60 mg/day) 1
Common Pitfalls to Avoid
Avoid methylprednisolone dose packs, which provide only 84-105 mg total over 6 days—grossly inadequate compared to the 500-540 mg total dose delivered by proper regimens 1, 6. This represents significant underdosing that may compromise outcomes.
Do not extend steroid duration beyond 10 days based on slow initial recovery, as most patients begin showing recovery within 2-3 weeks and complete recovery typically occurs within 3-4 months 1, 6. Approximately 70% of patients with complete paralysis recover fully within 6 months, and those with incomplete paralysis achieve up to 94% recovery 1.
Essential Concurrent Management
While the steroid course should not be extended, aggressive eye protection must be implemented immediately and continued throughout recovery for any patient with impaired eye closure 1, 6:
- Lubricating ophthalmic drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime 1
- Eye taping or patching with proper technique instruction 1
- Sunglasses for outdoor protection 1
Follow-Up Algorithm
Mandatory reassessment or specialist referral is required at 3 months if facial recovery remains incomplete 1, 6. Earlier urgent referral is indicated for 1:
- New or worsening neurologic findings at any point
- Development of ocular symptoms at any point
- Progressive weakness beyond 3 weeks (suggests alternative diagnosis) 1
Special Population Considerations
In children, the evidence for steroid benefit is less conclusive, with a 2022 randomized trial (n=187) showing no significant difference between prednisolone and placebo at 1 month (49% vs 57% recovery) 7. However, children have excellent prognosis with 90% spontaneous recovery rates 1, 8. The 10-day regimen remains appropriate if treatment is chosen, but should involve caregiver participation in shared decision-making 1.
For pregnant women and diabetic patients, the 10-day prednisolone regimen should still be used with individualized assessment, as the therapeutic benefit outweighs risks when proper glucose monitoring is implemented 1.