What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Oral corticosteroids are strongly recommended as first-line treatment for Bell's palsy, with a regimen of prednisone 50-60 mg daily for 5 days followed by a 5-day taper. 1, 2

Recommended Treatment Algorithm

First-Line Treatment

• Corticosteroids: Start within 72 hours of symptom onset
  • Prednisone 50-60 mg daily for 5 days, followed by a 5-day taper 1, 2
  • High-quality evidence shows significantly improved recovery rates with early steroid administration 1, 3
  • Corticosteroids increase complete recovery rates from 63.6% to 83.0% at 3 months and from 81.6% to 94.4% at 9 months 3

Optional Additional Treatment

• Antiviral therapy: Consider adding to corticosteroids
  • Options include valacyclovir (1 g three times daily for 7 days) or acyclovir (400 mg five times daily for 10 days) 1, 2
  • Evidence shows minimal additional benefit when combined with steroids 1
  • Antivirals alone are ineffective and not recommended 2, 3

Eye Protection (Critical)

• For patients with impaired eye closure:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Tape eyelids closed if necessary 1

Additional Supportive Measures

• Physical therapy: May be beneficial for patients with more severe paralysis 2
• Dysphagia management: Provide supportive care and refer to a facial nerve specialist if swallowing difficulties persist beyond 3 months 1

Important Clinical Considerations

Diagnosis

• Bell's palsy is a diagnosis of exclusion characterized by acute onset of unilateral facial weakness/paralysis involving the forehead without other neurologic abnormalities 2
• Laboratory testing and imaging are not routinely required for diagnosis 1, 2

Prognosis

• Overall prognosis is good with more than two-thirds of patients experiencing complete spontaneous recovery 2
• Recovery rates are higher in children and pregnant women (up to 90%) 2
• Early treatment with corticosteroids significantly improves complete recovery rates 3

Special Populations

• Elderly patients: Treatment with corticosteroids is particularly beneficial, with studies showing 100% recovery in treated patients over 60 years compared to only 42% in untreated patients 4
• Pregnant women: Higher risk of Bell's palsy but better recovery rates (up to 90%) 2, 5
• Diabetic patients: Higher risk of Bell's palsy 5

Recent Research Perspectives

Some emerging research suggests high-dose corticosteroids (≥80 mg) may be more effective than standard doses (40-60 mg), with one meta-analysis showing decreased non-recovery rates at 6 months (OR = 0.17,95% CI = 0.05-0.56) 6. However, this research has serious risk of bias and requires further validation before changing standard practice 6.

Common Pitfalls to Avoid

• Delayed treatment: Starting corticosteroids beyond 72 hours after symptom onset may reduce effectiveness
• Using antivirals alone: Not effective as monotherapy 2, 3
• Neglecting eye protection: Critical to prevent corneal damage in patients with incomplete eye closure
• Missing other causes: Ensure Bell's palsy is truly idiopathic and not due to other conditions requiring different management
• Inadequate follow-up: Patients with persistent symptoms beyond 3 months should be referred to specialists 1