What is the recommended medication regimen, including dosage and taper, for acute Bell's palsy in adults, and how should comorbidities such as diabetes, hypertension, peptic ulcer disease, or osteoporosis influence the use of oral glucocorticoids and antiviral agents?

Bell's Palsy Medication Regimen

Primary Treatment: Oral Corticosteroids

For adults ≥16 years with Bell's palsy, prescribe oral corticosteroids within 72 hours of symptom onset using either prednisolone 50 mg once daily for 10 days (no taper) OR prednisone 60 mg once daily for 5 days followed by a 5-day taper (60→50→40→30→20→10 mg, stopping on day 11). 1

Evidence Supporting Corticosteroids

• Prednisolone achieves 83% complete recovery at 3 months versus 63.6% with placebo (absolute benefit 19.4%; NNT=6), and 94.4% recovery at 9 months versus 81.6% with placebo 1, 2
• Treatment must be initiated within 72 hours; no evidence supports benefit beyond this window 1, 3
• The 72-hour deadline exists because early corticosteroids reduce facial nerve inflammation before permanent damage occurs 1, 4

Critical Dosing Details

• Administer as a single daily dose, not divided doses, to optimize anti-inflammatory effect 1
• Maximum daily dose is 60 mg 1
• Avoid methylprednisolone dose packs—they deliver only ~84 mg total over 6 days, grossly inadequate compared to the required 540 mg prednisone-equivalent over 10-14 days 1, 4

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Antiviral Therapy: Optional Adjunct Only

Antiviral monotherapy is never appropriate for Bell's palsy and should never be prescribed alone. 1, 2

When to Consider Adding Antivirals

• May optionally add valacyclovir 1000 mg three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours 1
• The incremental benefit is small: one trial showed 96.5% recovery with combination therapy versus 89.7% with steroids alone (absolute benefit 6.8%; NNT=14) 1, 5
• The highest-quality trial (BELLS study, n=496) found no statistically significant advantage: 71.2% recovery with acyclovir versus 75.7% without at 3 months (P=0.50) 1, 2
• Combination therapy may reduce long-term sequelae (motor synkinesis, crocodile tears): RR 0.56 versus corticosteroids alone 6

Guideline Position

The American Academy of Otolaryngology-Head and Neck Surgery classifies antiviral addition as an "option" rather than a recommendation, emphasizing shared decision-making 1. Corticosteroids alone remain the evidence-based standard of care. 1, 2

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Management of Comorbidities

Diabetes Mellitus

Diabetes is NOT a contraindication to corticosteroids; the therapeutic benefit outweighs the risk of temporary hyperglycemia. 1

Glucose Management Algorithm

1. Monitor capillary blood glucose every 2-4 hours during the first few days of steroid therapy 1
2. Dose steroids in the morning to align with natural cortisol rhythm and produce predictable daytime hyperglycemia 1
3. Proactively adjust diabetes medications:
   • Increase basal insulin dose 1
   • Add or increase prandial insulin to counter steroid-induced hyperglycemia 1
   • For patients on oral agents, add NPH insulin concurrent with morning steroid dose (NPH peaks 4-6 hours later, matching hyperglycemic effect) 1
4. Higher steroid doses may require substantial increases in prandial and correctional insulin 1

Hypertension

• Hypertension is a risk factor for Bell's palsy but does not contraindicate corticosteroid use 1
• Monitor blood pressure during steroid therapy; short-term corticosteroids (10 days) rarely cause clinically significant hypertension in controlled patients 1

Peptic Ulcer Disease

• Consider adding a proton pump inhibitor during the 10-day steroid course for patients with active or recent peptic ulcer disease 1
• The short duration of therapy (10 days) carries lower GI risk than chronic steroid use 1

Osteoporosis

• A 10-day course of corticosteroids does not require bone protection or calcium/vitamin D supplementation 1
• Osteoporosis is not a contraindication to short-term, high-dose corticosteroids for Bell's palsy 1

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Essential Concurrent Eye Protection

All patients with impaired eye closure require aggressive eye protection to prevent corneal damage. 1, 4

Eye Protection Protocol

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching at night with proper technique instruction to avoid corneal abrasion 1
• Sunglasses outdoors to shield against wind and debris 1
• Moisture chambers (polyethylene covers) for severe cases 1

Urgent Ophthalmology Referral Indications

• Severe impairment with complete inability to close the eye 1
• Signs of corneal exposure or damage (pain, redness, vision changes) 1
• Persistent lagophthalmos beyond 3 months 1

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Special Populations

Pregnancy

• Treat pregnant women with oral corticosteroids within 72 hours after individualized risk-benefit assessment 1
• Eye protection measures are essential and safe in pregnancy 1
• Combination antiviral therapy may be considered on an individualized basis 1

Children

• Children have better prognosis with higher spontaneous recovery rates (up to 94%) than adults 1, 3
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper for severe cases, with substantial caregiver involvement in decision-making 1

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Follow-Up and Referral Triggers

Mandatory Reassessment at 3 Months

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1, 4

Urgent Referral Indications (Any Time)

• New or worsening neurologic findings 1
• Development of ocular symptoms 1
• Progressive weakness beyond 3 weeks 1

Red Flags Requiring Immediate MRI with Contrast

• Recurrent paralysis on the same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• Bilateral facial weakness 1
• Forehead sparing (suggests central stroke) 1
• No recovery after 3 months 1

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What NOT to Do

Diagnostic Testing to Avoid

• Do not order routine laboratory tests—they delay treatment beyond the 72-hour window without improving outcomes 1
• Do not obtain routine imaging for typical Bell's palsy presentations 1
• Do not perform electrodiagnostic testing in patients with incomplete facial paralysis 1

Ineffective Therapies

• Never prescribe antiviral monotherapy—it is ineffective and delays appropriate corticosteroid treatment 1, 2
• Do not recommend acupuncture or physical therapy—no proven benefit over spontaneous recovery 1
• Surgical decompression is not indicated except in rare, highly selected cases at specialized centers 1

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Common Pitfalls

1. Starting treatment beyond 72 hours—provides minimal benefit and exposes patients to medication risks without proven efficacy 1, 3
2. Using methylprednisolone dose packs—grossly inadequate dosing 1, 4
3. Prescribing antivirals alone—ineffective as monotherapy 1, 2
4. Inadequate eye protection—can lead to permanent corneal damage 1, 4
5. Failing to refer at 3 months—delays access to reconstructive options 1, 4
6. Ordering unnecessary labs or imaging—increases cost, delays treatment, offers no clinical benefit 1