What is the initial treatment for a patient diagnosed with Bell's palsy?

Initial Treatment for Bell's Palsy

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

Diagnostic Considerations

Bell's palsy should be suspected in patients with:

• Acute onset of unilateral facial weakness or paralysis
• Involvement of the forehead (distinguishing from central causes)
• Absence of other neurologic abnormalities 2

Laboratory testing and imaging are not required for the initial diagnosis of typical Bell's palsy 2.

Treatment Algorithm

First-Line Treatment

1. Oral Corticosteroids
   • Prednisone 60-80mg daily for 7 days with taper 1
   • Alternative regimen: Prednisone 50-60mg daily for 5 days followed by a 5-day taper 2
   • Must be started within 72 hours of symptom onset for maximum effectiveness
   • Improves recovery rates from 70% to 94% 1

Optional Additional Treatment

• Antiviral Therapy (may be offered as an addition to steroid therapy)
  • Valacyclovir 1g three times daily for 7 days, OR
  • Acyclovir 400mg five times daily for 10 days 1, 2
  • Note: Evidence for benefit is mixed (RR 0.75,95% CI 0.56-1.00) 1
  • Antivirals alone without steroids are ineffective and not recommended 2

Important Considerations

• Contraindications to steroids include diabetes, morbid obesity, and previous steroid intolerance 1
• Treatment with prednisolone within 48 hours of onset results in significantly higher complete recovery rates compared to later treatment 3
• Age considerations: Patients aged 40 years or older show significantly higher complete recovery rates with prednisolone treatment 3

Mandatory Eye Protection

For patients with impaired eye closure:

• Artificial tears
• Lubricating ophthalmic drops/ointments
• Eye patching or taping
• Moisture chambers
• Sunglasses for daytime protection 1

Follow-up and Referral

• Reassess after 3 months if incomplete recovery 1
• Refer to a facial nerve specialist if:
  • New or worsening neurologic findings develop
  • Ocular symptoms occur
  • Incomplete facial recovery after 3 months 1

Prognosis

• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery
• With corticosteroid treatment, recovery rates improve to 87-94% 1, 4
• Children and pregnant women have up to 90% complete recovery rate 2

Treatment Efficacy Evidence

Recent research shows significantly better outcomes in patients treated with corticosteroids compared to no treatment, with particularly pronounced benefits in elderly patients 4. Studies comparing combination therapy (antivirals plus steroids) versus steroids alone show some additional benefit in reducing synkinesis (involuntary co-contraction of facial muscles) with combination therapy 2, 5.

Physical therapy may be beneficial for patients with more severe paralysis, though evidence regarding standardized protocols is inconclusive 1, 2.