What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Oral corticosteroids, specifically prednisone 60-80 mg daily for 7 days with a taper, are strongly recommended as first-line treatment for Bell's palsy and should be started within 72 hours of symptom onset. 1

Treatment Algorithm

First-Line Treatment

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

Optional Additional Treatment

• Antiviral therapy: May be considered in addition to steroids (not as monotherapy) 1
  • Options include:
    • Valacyclovir 1 g three times daily for 7 days, or
    • Acyclovir 400 mg five times daily for 10 days
  • Evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00)
  • Some studies suggest combination therapy may reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2

Critical Eye Protection Measures

• Strongly recommended for patients with impaired eye closure 1
  • Artificial tears during the day
  • Lubricating ophthalmic ointments at night
  • Eye patching or taping
  • Moisture chambers
  • Aggressive eye protection is essential to prevent corneal damage

Evidence Analysis

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends corticosteroids as the cornerstone of Bell's palsy treatment 1. This recommendation is supported by high-quality evidence demonstrating significantly improved recovery rates with early steroid administration.

A 2007 randomized controlled trial published in the New England Journal of Medicine found that at 9 months, 94.4% of patients treated with prednisolone had complete recovery compared to only 81.6% of those who did not receive prednisolone (P<0.001) 3. This study also found no significant benefit from acyclovir alone and no additional benefit when acyclovir was combined with prednisolone.

However, some conflicting evidence exists regarding combination therapy. A 2007 multicenter randomized controlled trial found that valacyclovir plus prednisolone resulted in a significantly better recovery rate (96.5%) compared to prednisolone alone (89.7%), particularly in cases of complete or severe palsy 4. This suggests that antiviral therapy may provide some additional benefit in certain cases, which is why it remains an optional recommendation.

Special Considerations

• Timing is critical: Treatment benefits diminish significantly if initiated beyond 72 hours after symptom onset 1
• Natural recovery: Without treatment, approximately 70-94% of patients recover completely, but early treatment improves these odds 1
• Special populations:
  • Children and pregnant women have higher spontaneous recovery rates (up to 90%) 2
  • Elderly patients may particularly benefit from combination therapy 5
  • Diabetic patients, pregnant women, and those with previous steroid intolerance require individualized treatment approaches 1

Follow-up Recommendations

• 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
• Physical therapy may be beneficial for patients with more severe paralysis 2
• Reconstructive procedures may be considered for patients with persistent or severe Bell's palsy 1

Common Pitfalls to Avoid

1. Delaying treatment: Starting corticosteroids after 72 hours significantly reduces effectiveness
2. Using antivirals alone: Antivirals without steroids are ineffective and not recommended 2, 3
3. Neglecting eye protection: Failure to protect the eye in patients with incomplete eye closure can lead to corneal damage
4. Misdiagnosis: Bell's palsy affects all branches of the facial nerve, including the forehead, whereas strokes typically spare forehead movement 1
5. Missing bilateral involvement: Bilateral Bell's palsy is rare and should prompt investigation for other conditions such as Guillain-Barré syndrome or Lyme disease 1