In a patient presenting to the emergency department with acute Bell's palsy, what is the recommended oral corticosteroid regimen (dose, duration, taper), and how should it be adjusted for children, pregnant patients, diabetics, and individuals with contraindications, and when should antiviral therapy be added?

Corticosteroid Recommendations for Bell's Palsy in the Emergency Department

Immediate Treatment for Adults (≥16 Years)

Initiate oral corticosteroids within 72 hours of symptom onset—this is the only treatment window with proven efficacy. 1

Standard Dosing Regimens

Choose one of the following evidence-based regimens:

• Prednisolone 50 mg once daily for 10 days (no taper required), OR 1
• Prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1

Both regimens demonstrate equivalent efficacy: 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 (NNT = 8). 1, 2, 3

Critical Timing Considerations

• Treatment initiated beyond 72 hours provides no proven benefit and should not be started. 1, 4 The clinical trials demonstrating steroid efficacy specifically enrolled patients within this window. 4
• Patients presenting at day 4 or later should receive supportive care only (eye protection) rather than corticosteroids. 4

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Special Populations

Diabetic Patients

Diabetes is NOT a contraindication to corticosteroid therapy—the therapeutic benefit outweighs the risk of temporary hyperglycemia. 1

Glucose management protocol:

• Monitor capillary blood glucose every 2–4 hours during the first few days of treatment 1
• Administer steroids in the morning to align with natural cortisol rhythm 1
• For patients on basal insulin: increase the basal dose and add or increase prandial insulin 1
• For patients on oral agents only: add NPH insulin concurrent with the morning steroid dose (NPH peaks 4–6 hours later, matching steroid-induced hyperglycemia) 1
• Higher steroid doses may require substantial increases in both prandial and correctional insulin 1

Pregnant Patients

Prescribe oral corticosteroids within 72 hours using the same dosing regimens as non-pregnant adults. 1 While guidelines recommend "individualized assessment," the evidence supports treatment because:

• The 72-hour window for efficacy applies equally 1
• Eye protection measures are essential and safe in pregnancy 1
• The benefit of preventing permanent facial paralysis outweighs theoretical corticosteroid risks 1

Pediatric Patients (<16 Years)

Children have higher spontaneous recovery rates (up to 94%) than adults, and the benefit of corticosteroids in pediatrics is unproven. 1

Treatment algorithm for children:

• Incomplete paralysis: Observation only—recovery rates approach 94% without treatment 1
• Complete paralysis with presentation within 72 hours: Consider prednisolone 1 mg/kg/day (maximum 50–60 mg) for 5 days followed by a 5-day taper, but only after discussing with caregivers that pediatric benefit is uncertain 1
• Presentation beyond 72 hours: Supportive care only 1

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Contraindications and Adjustments

Absolute Contraindications

• Active systemic fungal infection 1
• Known hypersensitivity to corticosteroids 1

Relative Contraindications Requiring Dose Adjustment

For patients significantly below or above average weight: Use weight-based dosing of 1 mg/kg/day prednisone (usual maximum 60 mg/day) to ensure adequate dosing across body sizes. 1

For patients with severe uncontrolled diabetes, active peptic ulcer, or severe osteoporosis: The guideline position is that the therapeutic benefit still outweighs risks for a 5–10 day course, but glucose monitoring and gastroprotection should be intensified. 1

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Antiviral Therapy

Strong Recommendation Against Monotherapy

Never prescribe acyclovir or valacyclovir alone—antiviral monotherapy is completely ineffective for Bell's palsy. 1, 5, 2, 3

Optional Combination Therapy

Adding an antiviral to corticosteroids within 72 hours is optional and provides only a small incremental benefit. 1

Evidence for combination therapy:

• One small trial showed 96.5% recovery with steroids + acyclovir versus 89.7% with steroids alone (absolute benefit +6.8%) 1, 6
• However, the large BELLS trial (n=496) found no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without (P=0.50) at 3 months 1, 2
• At 9 months: 85.4% with acyclovir versus 90.8% without 2, 3

If choosing combination therapy, use:

• Valacyclovir 1000 mg three times daily for 7 days, OR 1
• Acyclovir 400 mg five times daily for 10 days 1

The guideline classifies this as an "option" rather than a recommendation due to the minimal and inconsistent benefit. 1

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Mandatory Eye Protection (All Patients with Incomplete Eye Closure)

Implement comprehensive eye protection immediately—corneal damage can occur within hours. 1

Daytime Protection

• Lubricating ophthalmic drops (e.g., hydroxypropyl methylcellulose) every 1–2 hours while awake 1
• Sunglasses outdoors to shield against wind and debris 1

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching with proper technique instruction to avoid corneal abrasion 1
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Triggers

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 1

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Interventions to Avoid

Do NOT order:

• Routine laboratory tests—they delay treatment without improving outcomes 1
• Routine imaging—reserve MRI for atypical presentations only 1
• Electrodiagnostic testing for incomplete paralysis—it provides no actionable information 1
• Physical therapy or acupuncture—no proven benefit over spontaneous recovery 1
• Surgical decompression—rarely indicated except in specialized centers 1

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Mandatory Follow-Up and Referral Triggers

Refer to a facial nerve specialist if: 1

• 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

Red flags requiring immediate imaging (MRI with/without contrast): 1

• Recurrent paralysis on the same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Progressive weakness beyond 3 weeks 1
• Bilateral facial weakness 1

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Common Pitfalls

• Starting steroids beyond 72 hours: No evidence of benefit and exposes patients to medication risks 1, 4
• Prescribing antivirals alone: Completely ineffective and delays appropriate corticosteroid treatment 1, 5
• Inadequate eye protection: Can lead to permanent corneal damage, particularly in patients with complete paralysis 1
• Failing to refer at 3 months: Delays access to reconstructive options for the 30% who develop permanent weakness 1
• Withholding steroids in diabetics: The therapeutic benefit outweighs hyperglycemia risk for a 5–10 day course 1