From the Guidelines
Bell's palsy in a 24-year-old should be treated promptly with oral corticosteroids within 72 hours of symptom onset to improve outcomes and speed recovery. The treatment of choice is oral steroids, as evidenced by high-quality randomized controlled trials, such as the study by Sullivan et al 1, which reported significant improvement of facial nerve function in patients treated with prednisolone within 72 hours of onset.
Key Considerations
- The patient should be prescribed oral steroids, such as prednisone, as soon as possible after symptom onset, ideally within 72 hours.
- Antiviral therapy with valacyclovir may be added, especially if there are signs of herpes infection or if symptoms are severe, as suggested by the guideline 1.
- Eye care is crucial, and the patient should protect the affected eye with artificial tears during the day and lubricating ointment at night, along with taping the eye closed during sleep if incomplete eye closure is present, as recommended by the guideline 1.
- Physical therapy with facial exercises and massage may help maintain muscle tone, although the evidence for this is not as strong.
Treatment Approach
- The patient should be reassured about the generally good prognosis, but if no improvement occurs within 3 months or symptoms worsen, further neurological evaluation is warranted to rule out other conditions, as recommended by the guideline 1.
- The role of patient preference in making decisions deserves further clarification, and clinicians should provide patients with clear and comprehensible information on the benefits to facilitate patient understanding and shared decision making, which in turn leads to better patient adherence and outcomes, as discussed in the guideline 1.
From the Research
Diagnosis of Bell's Palsy
- Bell's palsy should be suspected in patients with acute onset of unilateral facial weakness or paralysis involving the forehead in the absence of other neurologic abnormalities 2.
- The presentation of Bell's palsy is unmistakable by a trained clinician, usually presenting with unilateral facial weakness, reduced forehead wrinkling, nasolabial fold flattening, drooping of the corner of the mouth, and drooling 3.
Treatment of Bell's Palsy
- An oral corticosteroid regimen (prednisone, 50 to 60 mg per day for five days followed by a five-day taper) is the first-line treatment for Bell's palsy 2.
- Combination therapy with an oral corticosteroid and antiviral may reduce rates of synkinesis (misdirected regrowth of facial nerve fibers manifesting as involuntary co-contraction of certain facial muscles) 2, 4.
- Recommended antivirals include valacyclovir (1 g three times per day for seven days) or acyclovir (400 mg five times per day for 10 days) 2.
- Treatment with antivirals alone is ineffective and not recommended 2, 4, 5.
Prognosis of Bell's Palsy
- The overall prognosis is good, with more than two-thirds of patients with typical Bell's palsy having a complete spontaneous recovery 2.
- For children and pregnant women, the rate of complete recovery is up to 90% 2.
- Most patients will recover fully within six months regardless of the treatment 3.
- A study found that treatment with valacyclovir and prednisone resulted in a significantly better outcome in patients with Bell's palsy compared to patients given no medical treatment, especially among elderly patients 6.