Bell's Palsy Medications
Prescribe oral corticosteroids (prednisolone 60 mg daily for 5 days followed by a 5-day taper, or prednisolone 50 mg daily for 10 days) within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy. 1
Primary Treatment: Corticosteroids
The evidence is unequivocal that oral corticosteroids are the cornerstone of Bell's palsy treatment. Two large, high-quality randomized controlled trials demonstrated significant improvement in facial nerve recovery:
- Sullivan et al. (551 patients): 83% recovery at 3 months with prednisolone vs. 63.6% with placebo (P < .001); 94.4% vs. 81.6% recovery at 9 months 1
- Engstrom et al. (829 patients): Statistically significant shorter recovery times in the 416 patients treated with prednisolone 1
Dosing Regimens
Two validated approaches exist 1:
- Option 1: Prednisolone 60 mg daily for 5 days, then taper over 5 days
- Option 2: Prednisolone 25 mg twice daily (50 mg total) for 10 days
Critical timing: Treatment must begin within 72 hours of symptom onset. Benefit after 72 hours is unclear and not supported by evidence 1.
Antiviral Therapy: Optional Add-On
Do not prescribe antivirals as monotherapy—they are ineffective alone. 1 The evidence clearly shows antiviral monotherapy is no better than placebo for facial nerve recovery.
Combination Therapy Consideration
You may offer antivirals in addition to steroids within 72 hours, but this is optional with equilibrium of benefit and harm 1. The decision requires shared decision-making with the patient.
If adding antivirals, use: 2
- Valacyclovir 1 g three times daily for 7 days, OR
- Acyclovir 400 mg five times daily for 10 days
Recent meta-analysis data suggest famciclovir, valacyclovir, and acyclovir (in that order) show the most synergistic effect with corticosteroids 3. Some smaller trials found combination therapy achieved 96.5% full recovery at 6 months vs. 89.7% with steroids alone, though these had methodological limitations 1.
When to consider adding antivirals:
- Severe paralysis (complete facial paralysis)
- Early-onset disease
- Patient preference after discussing limited evidence 4
Special Populations
Children (<16 years)
Evidence for steroid use in children is inconclusive. Children show higher spontaneous recovery rates than adults 1. Despite lack of quality trials, oral steroids may be considered given the presumed similar disease process and favorable benefit-harm ratio, with significant caregiver involvement in decision-making 1.
Pregnant Women
Treatment should be individualized 1. The guidelines acknowledge pregnancy as a potential exception requiring careful consideration of steroid risks.
Essential Eye Protection
Implement eye protection immediately for all patients with impaired eye closure (strong recommendation) 1:
- Lubricating ophthalmic drops (frequent administration)
- Ophthalmic ointments at night
- Eye patching or taping
- Moisture chamber if needed
- Sunglasses for outdoor protection
Incomplete eyelid closure can lead to corneal abrasions, exposure keratitis, and corneal ulcerations. Monitor for burning, itching, eye irritation, vision changes, and pain 1.
Common Pitfalls to Avoid
- Delayed treatment: Starting steroids after 72 hours significantly reduces effectiveness
- Antiviral monotherapy: Never prescribe antivirals alone—they don't work without steroids 1
- Routine imaging: Do NOT order CT/MRI for typical Bell's palsy presentation 1. Only image if atypical features present (bilateral palsy, other cranial nerve involvement, no recovery after 3 months, or history of trauma/tumor)
- Routine laboratory testing: Avoid unnecessary Lyme serology or other tests in typical presentations 5
- Neglecting eye care: This is mandatory, not optional, for patients with lagophthalmos
Treatment Algorithm
Within 72 hours of symptom onset:
- Confirm diagnosis (acute unilateral facial weakness, no other neurologic findings)
- Start prednisolone 60 mg daily × 5 days, then taper × 5 days
- Implement eye protection measures
- Consider adding valacyclovir 1 g TID × 7 days if severe paralysis or patient preference
- Reassess at 3 months—refer to facial nerve specialist if incomplete recovery
The 2013 AAO-HNS guidelines remain the authoritative source, with recent international guidelines (Japanese 2023, French 2020, Korean 2026) consistently supporting early corticosteroid therapy as the primary intervention 6, 4, 7.