Bell's Palsy: Acyclovir + Prednisolone Dosing

• Prednisolone/prednisone 50-60 mg/day for 10 days, OR
• Prednisolone 60 mg/day for 5 days followed by a 5-day taper (total 10-day course)
• Alternative regimen used in the pivotal Scottish BELLS trial: prednisolone 25 mg twice daily (50 mg/day) for 10 days
• Must be started within 72 hours of symptom onset - benefit is markedly reduced or lost after this window
• Some protocols dose by weight: 1 mg/kg/day up to a maximum of 80 mg/day

• Acyclovir 400 mg five times daily for 7-10 days, OR
• Valacyclovir 1000 mg three times daily for 7 days (valacyclovir is generally preferred now due to better bioavailability/compliance)
• Acyclovir/antivirals should never be used alone - trial and Cochrane evidence (Gagyor et al., cited in Scott-Brown's) found no benefit from antivirals as monotherapy, and the same Scottish study found "no evidence of additional benefit from oral antiviral medication in the form of acyclovir" when added to steroid in the overall population.
• Current AAN/AAO-HNS guidance: antiviral + steroid combination is offered particularly in severe-to-complete facial palsy, with patients counselled that any added benefit over steroid alone is small and evidence quality is low-to-moderate.

• Prednisolone 50-60 mg/day x 5-10 days (taper if using the 5+5 regimen)
• PLUS Acyclovir 400 mg 5x/day x 7-10 days (or valacyclovir 1g TID x 7 days) - added especially for severe presentations, started together within 72 hours of onset

• AAN 2012 evidence-based guideline (Gronseth & Paduga, Neurology) - steroids are "highly likely effective," antivirals combined with steroids "possibly effective."
• AAO-HNS 2013 clinical practice guideline - strongly recommends 10-day corticosteroid course within 72 hours; antivirals may be added but not used alone.
• BELLS trial (Sullivan et al., NEJM 2007) and the Swedish/Finnish trial (Engström et al., Lancet Neurol 2008) are the two key RCTs underpinning current dosing.