What is the recommended treatment for Bell's palsy?

Treatment for 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

Diagnosis and Initial Assessment

Bell's palsy is defined as an acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without an identifiable cause. Before initiating treatment, clinicians should:

• Confirm rapid onset (<72 hours) of unilateral facial weakness
• Rule out other causes of facial paralysis (stroke, tumors, infections)
• Note that bilateral Bell's palsy is rare and should prompt investigation for other etiologies

Treatment Algorithm

First-line Treatment (Adults)

• Oral corticosteroids: Initiate 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

Antiviral Therapy

• Not recommended as monotherapy (strong recommendation against) 1
• Optional add-on therapy: May offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset 1
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 2

Eye Protection (Critical)

• Implement eye protection for all patients with impaired eye closure (strong recommendation) 1
  • Frequent lubricating eye drops during the day
  • Ophthalmic ointment at night
  • Consider moisture chamber or eye taping/patching, especially at night
  • Instruct patients carefully on proper execution of eye protection techniques

Special Populations

Children

• Evidence for steroid use in children is inconclusive
• Higher rates of spontaneous recovery than adults
• Consider oral steroids with caregiver involvement in decision-making 1

Pregnant Women

• Recovery rates up to 90% without treatment 2
• Consider risks and benefits of steroid therapy

Evidence Quality and Considerations

High-quality evidence supports the use of oral corticosteroids. A randomized, double-blind, placebo-controlled trial involving 551 patients showed that 83% of participants treated with prednisolone recovered facial function at 3 months compared to 63.6% with placebo (p<0.001). At 9 months, recovery rates were 94.4% for prednisolone versus 81.6% for placebo 1, 3.

The evidence for combination therapy (steroids plus antivirals) is mixed. Some smaller studies suggest benefit, with one showing 96.5% recovery with combination therapy versus 89.7% with steroids alone 1. However, a large trial found no additional benefit of acyclovir when combined with prednisolone 3.

Recent research suggests that high-dose corticosteroids (≥80 mg) may be more effective than standard doses, with significantly decreased non-recovery rates at 6 months (OR = 0.17,95% CI = 0.05-0.56) 4. However, this approach requires further validation before becoming standard practice.

Follow-up and Referral

Refer patients to a facial nerve specialist if:

• New or worsening neurologic findings develop
• Ocular symptoms develop at any point
• Incomplete facial recovery after 3 months 1

Common Pitfalls to Avoid

1. Delayed treatment: Initiate steroids within 72 hours of symptom onset for maximum benefit
2. Inadequate eye protection: Corneal damage can occur with improper eye care
3. Using antiviral therapy alone: Not effective as monotherapy
4. Missing atypical presentations: Features like bilateral involvement, isolated branch paralysis, or other cranial nerve involvement require further investigation
5. Inadequate follow-up: Patients with incomplete recovery at 3 months should be referred for specialist evaluation

Early treatment with oral corticosteroids significantly improves the chances of complete recovery and reduces the risk of long-term facial nerve dysfunction in patients with Bell's palsy.