Treatment of Bell's Palsy
Oral corticosteroids should be administered within 72 hours of symptom onset as the primary treatment for Bell's palsy, with a regimen of prednisone 60-80mg daily for 7 days followed by a gradual taper. 1
First-Line Treatment
Bell's palsy is an acute unilateral facial nerve paresis or paralysis of unknown cause that develops rapidly (within 72 hours). Treatment should be initiated promptly to maximize recovery potential.
Corticosteroid Therapy
- Timing: Must be started within 72 hours of symptom onset
- Regimen: Prednisone 60-80mg daily for 7 days, followed by a taper
- Evidence: High-quality evidence shows significant improvement in recovery rates from 70% to 94% with early steroid administration 1
- Efficacy: A randomized controlled trial demonstrated that prednisolone significantly improves complete recovery rates at both 3 months (83.0% vs 63.6%) and 9 months (94.4% vs 81.6%) 2
Adjunctive Treatments
Antiviral Therapy
- Optional addition to corticosteroid therapy
- Options:
- Valacyclovir 1g three times daily for 7 days, or
- Acyclovir 400mg five times daily for 10 days 1
- Evidence: Mixed benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
- Important note: Antiviral therapy alone is ineffective and not recommended 3
Eye Protection (Mandatory for patients with impaired eye closure)
- Artificial tears and lubricating eye drops/ointments
- Eye patches or adhesive tape
- Humid chambers
- Sunglasses for daytime protection 1
Special Considerations
Severe Bell's Palsy (House-Brackmann grades 5-6)
- Follow the same corticosteroid regimen
- Consider combination therapy with antivirals to potentially reduce long-term sequelae 4
Prevention of Sequelae
- Combination of antivirals and corticosteroids may reduce the risk of motor synkinesis (involuntary co-contraction of facial muscles) and crocodile tears compared to corticosteroids alone 4
Follow-Up and Referral
Re-evaluation Criteria
- New or worsening neurological findings
- Persistent ocular symptoms
- Incomplete facial recovery after 3 months 1
Specialist Referral
- Facial nerve specialist: For incomplete recovery after 3 months
- Neurologist: For new or worsening neurological findings
- Ophthalmologist: For persistent ocular symptoms 1
Prognosis
- Overall prognosis is good with more than two-thirds of patients experiencing complete spontaneous recovery
- Up to 90% of children and pregnant women achieve complete recovery 1, 3
- Early treatment with corticosteroids significantly improves outcomes 1, 2
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours of symptom onset
- Using antivirals alone without corticosteroids
- Neglecting eye protection in patients with impaired eye closure
- Failing to refer patients with incomplete recovery after 3 months
- Missing alternative diagnoses - ensure diagnosis is consistent with Bell's palsy (acute onset, unilateral facial weakness/paralysis, no other neurological deficits)