How to Taper Prednisone After a Short High-Dose Course for Bell's Palsy
After completing a 5-day course of prednisone 60 mg daily for Bell's palsy, taper by 10 mg every day over 5 days (50 mg, 40 mg, 30 mg, 20 mg, 10 mg) to complete a total 10-day treatment course. 1
Evidence-Based Tapering Regimens
The American Academy of Otolaryngology-Head and Neck Surgery guidelines provide two equally acceptable steroid regimens for Bell's palsy 1:
- Prednisolone 50 mg once daily for 10 days (no taper required) 1
- Prednisone 60 mg once daily for 5 days followed by a 5-day taper 1
For the second regimen, the taper schedule reduces the dose by 10 mg per day after the initial 5-day high-dose period 2. This means:
- Days 1-5: 60 mg daily
- Day 6: 50 mg
- Day 7: 40 mg
- Day 8: 30 mg
- Day 9: 20 mg
- Day 10: 10 mg
- Day 11: Stop
Why This Specific Taper?
The 10-day total duration with a 5-day taper is based on high-quality randomized controlled trials showing 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo. 1 The taper is rapid because this is a short-course, high-dose regimen designed to reduce acute facial nerve inflammation, not a prolonged immunosuppressive protocol 1.
The German guideline similarly recommends either 25 mg twice daily for 10 days or 60 mg daily for 5 days followed by 10 mg decrements per day 3. This consistency across international guidelines reinforces the evidence base 3.
Critical Timing Considerations
This taper schedule only applies when treatment is initiated within 72 hours of symptom onset—starting steroids after this window provides no proven benefit. 1, 4 The 72-hour window exists because early corticosteroid treatment reduces facial nerve inflammation before permanent damage occurs 4.
Common Pitfalls to Avoid
Do not use a standard methylprednisolone dose pack, which provides only 84 mg total prednisone equivalent over 6 days—this represents gross underdosing compared to the recommended 540 mg over 10-14 days for adequate treatment 2, 5. The methylprednisolone dose pack contains 4-mg tablets with 6 tablets on day 1 and one fewer each subsequent day, totaling only 105 mg prednisone equivalent 2.
Do not extend the taper beyond 10 days for uncomplicated Bell's palsy. Unlike chronic inflammatory conditions requiring slow tapers over 4-8 weeks 2, Bell's palsy treatment uses a short, aggressive course to address acute nerve inflammation 1.
Administer the entire daily dose as a single morning dose, not divided doses, to optimize the anti-inflammatory effect and align with natural cortisol rhythms 1.
Special Populations
For diabetic patients, the same taper schedule applies—diabetes is not a contraindication to corticosteroid therapy for Bell's palsy 1. However, monitor capillary blood glucose every 2-4 hours during the first few days and proactively adjust diabetes medications, particularly increasing basal and prandial insulin to counter steroid-induced hyperglycemia 1.
For pregnant women, the same regimen (prednisone 60 mg daily for 5 days followed by a 5-day taper) should be used within 72 hours of symptom onset after individualized risk-benefit assessment 1, 5.
For children, the evidence for steroid benefit is less conclusive, but if treatment is chosen, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper 1.
What This Taper Does NOT Apply To
This rapid taper is specific to Bell's palsy and other short-course, high-dose steroid indications 1. Do not use this schedule for:
- Chronic inflammatory conditions (polymyalgia rheumatica, inflammatory myopathies) requiring slow tapers over 4-8 weeks 2
- Immune checkpoint inhibitor toxicities requiring 4-6 week tapers 2
- Patients on chronic steroids being tapered to discontinuation 2
Concurrent Management During Taper
Implement aggressive eye protection immediately if the patient has impaired eye closure, regardless of where they are in the steroid taper 1, 4:
- Lubricating drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime 1
- Eye taping or patching at night with proper technique 1
- Sunglasses outdoors 1
Do not add antiviral monotherapy—antivirals alone are ineffective and should never be prescribed 1, 4. Combination antiviral plus steroid therapy may be considered within 72 hours for severe cases, but the added benefit is minimal (96.5% vs 89.7% recovery) 1.