What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

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

Recommended Treatment Algorithm

First-line Treatment

• Oral corticosteroids within 72 hours of symptom onset:
  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

Optional Additional Treatment

• Antiviral therapy may be offered in combination with oral steroids (but not as monotherapy):
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 1, 2

Eye Protection

• Mandatory eye protection for patients with impaired eye closure to prevent corneal damage 1
  • Artificial tears/lubricating eye drops during the day
  • Lubricating eye ointment at night
  • Eye patch or tape for complete closure if needed

Evidence Analysis

The recommendation for oral corticosteroids is based on high-quality randomized controlled trials that demonstrate significant improvement in facial nerve recovery. A large multicenter trial involving 829 patients showed statistically significant shorter recovery times in patients treated with prednisolone compared to those who did not receive it 1, 3. Another double-blind, placebo-controlled trial of 551 patients found that 83% of participants receiving prednisolone recovered facial function at 3 months compared to only 63.6% in the placebo group (p<0.001) 4.

Regarding antiviral therapy:

• Antiviral monotherapy is not recommended as it shows no benefit over placebo 1, 4
• Combination therapy with antivirals plus steroids may provide modest additional benefit in some patients, particularly in reducing synkinesis (involuntary facial muscle movements) 2, 5

Special Populations

Children

• Evidence for steroid use in children is less robust
• Children generally have higher rates of spontaneous recovery than adults
• Oral steroids may still be considered given the favorable benefit-harm ratio 1

Elderly Patients

• May particularly benefit from combination therapy
• One study showed 100% recovery in treated elderly patients versus only 42% in untreated controls 5

Follow-up Recommendations

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 of initial symptom onset 1

Important Caveats

• Timing is critical: Treatment should begin within 72 hours of symptom onset for maximum efficacy
• Diagnostic imaging and laboratory testing are not routinely recommended for typical Bell's palsy presentations 1
• Electrodiagnostic testing is not recommended for patients with incomplete facial paralysis but may be considered for those with complete paralysis 1
• Bell's palsy must be distinguished from other causes of facial weakness (stroke, tumors, Lyme disease, etc.) through careful history and physical examination 1