What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Patients with Bell's palsy should be treated with oral corticosteroids within 72 hours of symptom onset, with a regimen of prednisone 60-80mg daily for 7 days followed by a gradual taper. 1 This treatment significantly improves recovery rates from 70% to 94%, making it the cornerstone of Bell's palsy management.

Diagnosis Confirmation

• Acute onset (<72 hours) of unilateral facial weakness/paralysis
• Involvement of the forehead (distinguishing from central causes)
• No other neurological deficits
• No identifiable cause 1, 2

Treatment Algorithm

First-Line Treatment

• Oral corticosteroids:
  • Prednisone 60-80mg daily for 7 days followed by taper 1
  • Alternative regimen: Prednisone 50-60mg daily for 5 days followed by 5-day taper 2
  • Must be started within 72 hours of symptom onset for maximum efficacy
  • High-quality evidence shows significant improvement in recovery rates 1, 3

Optional Adjunctive Treatment

• Antiviral therapy may be offered in combination with steroids, though evidence of additional benefit is mixed:
  • Valacyclovir 1g three times daily for 7 days, OR
  • Acyclovir 400mg five times daily for 10 days 1, 2
  • The most recent high-quality evidence shows limited additional benefit when combined with steroids 3

Mandatory Eye Protection (for patients with impaired eye closure)

• Artificial tears during the day
• Lubricating eye ointment at night
• Eye patches or adhesive tape
• Humid chambers
• Sunglasses for daytime protection 1

Special Populations

• Elderly patients (>60 years): May particularly benefit from combination therapy with corticosteroids and antivirals, as one study showed 100% recovery in treated elderly patients versus only 42% in untreated controls 4
• Children and pregnant women: Have better natural prognosis (up to 90% complete recovery) 1, 2

Follow-up and Referral

• Reevaluate if:

  • New or worsening neurological findings
  • Ocular symptoms
  • Incomplete facial recovery after 3 months 1

• Consider referral to:

  • Facial nerve specialist for incomplete recovery after 3 months
  • Neurologist for new/worsening neurologic findings
  • Ophthalmologist for persistent ocular symptoms 1

Rehabilitation Options

• Physical therapy may be beneficial for patients with more severe paralysis 2
• For persistent facial weakness, consider:
  • Eyelid weights
  • Brow lifts
  • Static and dynamic facial slings 1

Common Pitfalls to Avoid

1. Delayed treatment: Starting corticosteroids after 72 hours significantly reduces efficacy
2. Neglecting eye protection: Can lead to corneal damage in patients with incomplete eye closure
3. Relying on antivirals alone: Not effective as monotherapy 2
4. Failing to distinguish Bell's palsy from other causes: Ensure proper diagnosis before treatment
5. Overlooking psychological impact: Consider psychological support for patients with persistent facial weakness 1

Prognosis

• Overall good prognosis: More than two-thirds of untreated patients have complete spontaneous recovery
• With early corticosteroid treatment: Recovery rates improve to approximately 94% 1, 2
• Poor prognostic indicators: Complete paralysis, older age, and delayed treatment 1