What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

Patients with Bell's palsy should be treated with oral corticosteroids within 72 hours of symptom onset as the cornerstone of treatment, with a recommended regimen of prednisone 60-80mg daily for 7 days followed by a taper. 1

Diagnosis and Initial Assessment

Bell's palsy is defined as:

• Acute unilateral facial nerve paresis or paralysis
• Develops rapidly (within 72 hours)
• No identifiable cause
• Involves facial weakness including the forehead 1, 2

Assessment should include:

• Evaluation of oral competence
• Assessment of all phases of swallowing
• Quantification using the House-Brackmann scale (grades 1-6) 1

First-Line Treatment

Corticosteroid Therapy

• Timing: Start within 72 hours of symptom onset
• Dosage: Prednisone 60-80mg daily for 7 days followed by taper
• Evidence: High-quality evidence shows improvement in recovery rates from 70% to 94% 1
• Efficacy: At 3 months, 83.0% of patients treated with prednisolone recovered facial function compared to 63.6% without prednisolone (p<0.001) 3

Eye Protection

• Mandatory for patients with impaired eye closure 1
• May include artificial tears, eye patches, or taping eyelids closed at night

Antiviral Therapy

• Not recommended as monotherapy 1, 2
• Optional as combination therapy with steroids
• Minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
• If used, options include:
  • Valacyclovir (1g three times daily for 7 days)
  • Acyclovir (400mg five times daily for 10 days) 2

Dosage Considerations

Recent evidence suggests high-dose corticosteroids (≥80mg prednisolone equivalent) may be more effective than standard doses:

• Meta-analysis showed significant decrease in non-recovery with high-dose corticosteroids at 6 months (OR = 0.17,95% CI = 0.05-0.56, p = 0.004) 4
• Particularly beneficial for severe cases with Yanagihara scores of 0-10 5
• Most effective when started within 3 days of symptom onset 5

Follow-Up and Referral

Refer to specialists if:

• Swallowing difficulties persist beyond 3 months
• New or worsening neurological findings
• Ocular symptoms develop
• Incomplete facial recovery after 3 months 1

For incomplete recovery, consider:

• Physical therapy (beneficial for more severe paralysis) 2
• Reconstructive procedures (eyelid weights, brow lifts, facial slings) 1

Prognosis

• Without treatment: More than two-thirds of patients experience complete spontaneous recovery 1, 2, 6
• With early corticosteroid treatment: Recovery rates improve to approximately 94% 1, 3
• Children and pregnant women: Up to 90% complete recovery rate 2

Common Pitfalls to Avoid

1. Delaying treatment - Corticosteroids are most effective when started within 72 hours
2. Using antivirals alone - Not effective as monotherapy
3. Neglecting eye protection - Critical to prevent corneal damage
4. Missing other causes - Bell's palsy is a diagnosis of exclusion
5. Inadequate follow-up - Patients with incomplete recovery at 3 months need specialist referral

The evidence strongly supports early corticosteroid treatment as the mainstay of therapy for Bell's palsy, with high-dose regimens potentially offering additional benefits for severe cases.