What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Oral corticosteroids should be prescribed within 72 hours of symptom onset as the primary treatment for Bell's palsy in patients 16 years and older. 1

First-Line Treatment

Adults (16 years and older)

• Oral corticosteroid regimen:
  • Prednisolone 50-60 mg daily for 5 days followed by a 5-day taper 1, 2
  • OR Prednisolone 25 mg twice daily for 10 days 1
  • Start within 72 hours of symptom onset for maximum effectiveness

Children

• Evidence for steroid use in children is less conclusive 1
• Children generally have better spontaneous recovery rates than adults 1
• Oral steroids may be considered on a case-by-case basis with caregiver involvement in decision-making 1

Antiviral Therapy

• Antiviral monotherapy is NOT recommended and should not be prescribed alone 1
• Combination therapy (antiviral plus corticosteroid) may be offered as an option within 72 hours of symptom onset 1, 3
• If using combination therapy, options include:
  • Valacyclovir 1 g three times daily for 7 days 2, 3
  • OR Acyclovir 400 mg five times daily for 10 days 2

Evidence for Combination Therapy

• Some studies show improved outcomes with combination therapy:
  • One trial showed 96.5% recovery with valacyclovir plus prednisolone vs. 89.7% with prednisolone alone 1, 3
  • Particularly beneficial in cases of complete or severe palsy 3
• However, large high-quality trials have not consistently proven significant benefit 1

Eye Protection

• Eye protection is mandatory for patients with impaired eye closure 1
• Implement measures to prevent corneal damage:
  • Lubricating eye drops during the day
  • Lubricating ointment at night
  • Tape eyelid closed during sleep if needed
  • Protective eyewear (sunglasses) during the day

Follow-up and Referral

• Patients should be reassessed or referred to a facial nerve specialist if:
  1. New or worsening neurologic findings develop at any point
  2. Ocular symptoms develop at any point
  3. Incomplete facial recovery after 3 months 1

Physical Therapy

• May be beneficial for patients with more severe paralysis 2
• However, evidence is limited and no strong recommendation can be made regarding its effectiveness 1

Important Clinical Considerations

• Bell's palsy is diagnosed when no other medical etiology is identified as a cause of facial weakness 1
• Bell's palsy is rapid in onset (< 72 hours) and typically unilateral 1
• Bilateral Bell's palsy is rare and should prompt investigation for other causes 1
• Routine laboratory testing and imaging are not required for diagnosis 1, 2
• Electrodiagnostic testing is not recommended for patients with incomplete facial paralysis 1

Treatment Pitfalls to Avoid

1. Delayed treatment - Corticosteroids should be started within 72 hours of symptom onset for maximum benefit 1
2. Using antiviral therapy alone - This is ineffective and not recommended 1, 2
3. Neglecting eye protection - Can lead to corneal damage, abrasions, or ulcerations 1
4. Missing atypical presentations - Features such as slow progression, involvement of other cranial nerves, or bilateral involvement require further investigation 1

The strongest evidence supports early corticosteroid treatment as the cornerstone of Bell's palsy management, with combination therapy with antivirals as an option in selected cases.