What are the treatment recommendations for Bell's palsy?

From the Guidelines

Bell's palsy patients 16 years and older should be prescribed oral steroids within 72 hours of symptom onset. This recommendation is based on 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. The study found that 83% of participants randomized to prednisolone had recovered facial nerve function 3 months after treatment, compared to 63.6% of those randomized to placebo. Another study by Engstrom et al, also cited in the guideline 1, found statistically significant shorter times to recovery in patients treated with prednisolone.

Key Treatment Recommendations

• Oral corticosteroids, such as prednisone, should be started within 72 hours of symptom onset to reduce inflammation and improve recovery rates.
• Antiviral medications like valacyclovir may be added, particularly if herpes simplex virus is suspected, though evidence for their benefit is less robust than for steroids 1.
• Eye protection is crucial for patients who cannot close their affected eye completely, including artificial tears during the day, lubricating ointment at night, and possibly taping the eye closed or using an eye patch to prevent corneal damage 1.
• Physical therapy with facial exercises and massage may help maintain muscle tone and stimulate nerve function during recovery, although the evidence for its effectiveness is not as strong as for corticosteroids 1.

Important Considerations

• Most patients (about 85%) recover completely within 3 months without treatment, but early corticosteroid therapy increases the likelihood of full recovery and reduces the risk of long-term facial weakness.
• If no improvement occurs within 3 months or symptoms worsen, further evaluation is recommended to rule out other causes of facial paralysis such as tumors or stroke 1.
• Patient preference and shared decision making should be taken into account when making treatment decisions, particularly in cases where the evidence is weak or benefits are unclear 1.

From the Research

Treatment Recommendations for Bell's Palsy

The treatment recommendations for Bell's palsy include:

• Early intake of prednisone (1 mg/kg body weight for up to 70 or 80 mg/day) or the combined use of prednisone and acyclovir (or valacyclovir) within 72 h following the onset of paralysis to improve the outcome of Bell's palsy 2
• The use of local superficial heat therapy, massage, exercises, electrical stimulation, and biofeedback training in the treatment of lower motor facial palsy, with each modality having its indications 2
• Corticosteroids, such as prednisolone, significantly improve the chances of complete recovery at 3 and 9 months, with no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone 3
• Treatment with valacyclovir and prednisone resulting in a significantly better outcome in patients with Bell's palsy compared to patients given no medical treatment, especially among elderly patients 4

Antiviral Treatment

• The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in people with Bell's palsy compared to corticosteroids alone, but may reduce the late sequelae of Bell's palsy compared with corticosteroids alone 5
• Antivirals alone had no clear effect on incomplete recovery rates compared with placebo, but the result was imprecise 5

High-Dose Corticosteroids

• High-dose corticosteroids (≥80 mg) may have a favorable effect in the treatment of Bell's palsy, with a significant decrease in nonrecovery compared with standard-dose corticosteroids (40-60 mg) at 6 months follow-up 6
• However, the included studies had a serious risk of bias, and future research should focus on larger trials with more robust methodology to draw more valid conclusions 6

Key Points

• Early treatment with corticosteroids is recommended for Bell's palsy
• The use of antivirals in combination with corticosteroids may have little or no effect on rates of incomplete recovery, but may reduce late sequelae
• High-dose corticosteroids may have a favorable effect in the treatment of Bell's palsy, but more research is needed to confirm this finding 2, 3, 4, 5, 6