What is the first-line treatment for Bell's palsy?

First-Line Treatment for Bell's Palsy

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

Treatment Recommendations

Primary Treatment: Corticosteroids

• Oral corticosteroids should be initiated as early as possible, ideally within 72 hours of symptom onset
• Recommended regimen: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
• High-quality evidence shows significantly improved recovery rates with early steroid administration 1
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 3
• Recovery rates at 3 months: 83.0% with prednisolone vs. 63.6% without prednisolone (difference of +19.4%) 3
• Recovery rates at 9 months: 94.4% with prednisolone vs. 81.6% without prednisolone (difference of +12.8%) 3

Antiviral Therapy: Optional Add-on

• Antiviral therapy alone is ineffective and not recommended 2, 3
• Combination therapy with corticosteroids and antivirals may be considered to reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2
• If used, recommended antivirals include:
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 2
• Evidence for combination therapy shows minimal additional benefit compared to steroids alone (RR 0.75,95% CI 0.56-1.00) 1

Additional Management Considerations

Eye Protection

• Critical for patients with impaired eye closure to prevent corneal damage 1
• Interventions include:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Taping eyelids closed if necessary

Physical Therapy

• May be beneficial in patients with more severe paralysis 2
• Should be considered if recovery is delayed beyond 3 months

Special Populations

• Children and pregnant women have better prognosis with up to 90% complete spontaneous recovery 2
• Elderly patients may particularly benefit from treatment, with studies showing 100% recovery in treated patients over 60 years compared to 42% in untreated controls 4

Clinical Pearls and Pitfalls

• Timing is critical: Treatment should be initiated as early as possible, ideally within 72 hours of symptom onset
• Don't delay for testing: Laboratory testing and imaging are not required for diagnosis of typical Bell's palsy 2
• Avoid antiviral monotherapy: Treatment with antivirals alone is ineffective and not recommended 2, 3
• Monitor for eye complications: Inadequate eye protection can lead to corneal damage
• Follow-up is essential: Patients with persistent symptoms beyond 3 months should be referred to a facial nerve specialist 1

Prognosis

• Overall prognosis is good with more than two-thirds of patients experiencing complete spontaneous recovery 2
• Early treatment with corticosteroids significantly improves outcomes and reduces the risk of long-term sequelae 1, 3