What is the first-line treatment for Bell's palsy?

First-Line Treatment for Bell's Palsy

Oral corticosteroids are strongly recommended as the first-line treatment for Bell's palsy and should be administered within 72 hours of symptom onset. 1

Treatment Recommendations

Primary Treatment

• Oral corticosteroids:
  • Prednisone 60-80 mg daily for 7 days with taper 1
  • Alternatively, prednisolone 50-60 mg per day for 5 days followed by a 5-day taper 2
  • Should be initiated within 72 hours of symptom onset for maximum effectiveness 1, 3
  • High-quality evidence shows significantly improved recovery rates with early steroid administration 1

Timing Considerations

• Treatment within 24-48 hours shows significantly higher complete recovery rates (66-76%) compared to no prednisolone (51-58%) 3
• Benefits diminish when treatment is delayed beyond 72 hours 1

Optional Additional Treatment

• Antiviral therapy may be offered in addition to steroids (not as monotherapy) within 72 hours of symptom onset 4, 1
• Options include:
  • Valacyclovir (1 g three times daily for 7 days) 2
  • Acyclovir (400 mg five times daily for 10 days) 2
• Evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
• Multiple studies have failed to demonstrate significant benefit of antivirals alone 5, 6

Essential Eye Protection

• Eye protection is strongly recommended for patients with impaired eye closure 4, 1
• Protective measures include:
  • Artificial tears/lubricating ophthalmic drops
  • Lubricating ophthalmic ointments
  • Eye patching or taping
  • Moisture chambers
• Inadequate eye protection can lead to corneal damage, abrasions, exposure keratitis, and ulcerations 4, 1

Special Populations

• Exceptions for standard steroid therapy include:
  • Diabetes
  • Morbid obesity
  • Previous steroid intolerance
  • Pregnant women (should be treated on an individualized basis) 4
• Children and pregnant women have higher spontaneous recovery rates (up to 90%) 2

Prognosis and Follow-up

• Overall prognosis is good with more than two-thirds of patients experiencing complete spontaneous recovery 2
• With prednisolone treatment, complete recovery rates increase to 83% at 3 months and 94.4% at 9 months 5
• Patients should be reassessed or referred to a facial nerve specialist if:
  • New or worsening neurologic findings develop
  • Ocular symptoms occur
  • Incomplete facial recovery is observed after 3 months 1

Common Pitfalls to Avoid

1. Delaying treatment beyond 72 hours significantly reduces effectiveness
2. Using antivirals alone is ineffective and not recommended 2, 5
3. Neglecting eye protection in patients with incomplete eye closure can lead to serious corneal complications 4, 1
4. Failing to recognize red flags that might indicate alternative diagnoses (bilateral involvement, other cranial nerve deficits, vesicular lesions)
5. Not adjusting treatment for special populations like diabetic patients or pregnant women 4