What is the initial treatment for Bell's palsy?

Initial 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, 2

Diagnosis and Assessment

• Bell's palsy is defined as acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without identifiable cause 1
• Key diagnostic steps:
  • Confirm rapid onset of unilateral facial weakness (including forehead involvement)
  • Rule out other causes of facial paralysis through history and physical examination 1
  • No routine laboratory testing is needed 1
  • No routine diagnostic imaging is required 1

Treatment Algorithm

First-Line Treatment:

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

Antiviral Therapy:

• Do not use antiviral therapy alone - this is strongly recommended against 1, 2
• Optional add-on therapy: May consider adding antivirals to corticosteroids within 72 hours of symptom onset 1, 2
  • Valacyclovir 1 g three times daily for 7 days OR
  • Acyclovir 400 mg five times daily for 10 days 3

Eye Protection (Critical):

• Implement eye protection for all patients with impaired eye closure 1, 2:
  • Frequent lubricating eye drops during the day
  • Ophthalmic ointment at night
  • Consider moisture chamber or eye taping/patching

Evidence for Treatment Efficacy

High-quality evidence supports corticosteroid use:

• Sullivan et al. (2007) showed 83% recovery at 3 months with prednisolone vs. 63.6% with placebo (P<0.001) 4
• At 9 months, recovery rates were 94.4% with prednisolone vs. 81.6% with placebo (P<0.001) 4
• Number needed to treat (NNT) to achieve one additional complete recovery is 6 5

Special Considerations

Children:

• Evidence for steroid use in children is less robust
• Higher rates of spontaneous recovery than adults (up to 90%)
• Treatment decisions should involve caregivers 2, 3

Elderly Patients:

• May benefit significantly from treatment
• One study showed 100% recovery in treated patients over 60 years vs. 42% in untreated controls 6

Follow-up and Referral

Refer to a facial nerve specialist if:

• No improvement or worsening after 3 months
• New or worsening neurologic findings at any point
• Ocular symptoms developing at any point 1, 2

Common Pitfalls to Avoid

1. Delaying treatment beyond 72 hours (significantly reduces effectiveness)
2. Using antiviral therapy alone (ineffective and not recommended)
3. Neglecting eye protection (can lead to corneal damage)
4. Failing to recognize atypical presentations that may indicate alternative diagnoses
5. Missing follow-up for patients with incomplete recovery

The evidence clearly demonstrates that early treatment with oral corticosteroids significantly improves outcomes in Bell's palsy, with minimal risk of adverse effects when used appropriately.