What is the recommended treatment for Bell's palsy?

Treatment for Bell's Palsy

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

Initial Management

Corticosteroid Therapy

• Initiate oral corticosteroids within 72 hours of symptom onset for optimal efficacy 3
• Standard dosing: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 2
• High-dose corticosteroids (≥80 mg) may provide additional benefit compared to standard doses, with one meta-analysis showing decreased non-recovery rates at 6 months (OR = 0.17,95% CI = 0.05-0.56) 4
• Corticosteroid therapy significantly improves complete recovery rates:
  • 83.0% recovery at 3 months with prednisolone vs. 63.6% without 3
  • 94.4% recovery at 9 months with prednisolone vs. 81.6% without 3

Antiviral Therapy

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

Eye Protection

• Critical for patients with impaired eye closure to prevent corneal damage 1
• Implement the following measures:
  • Artificial tears during daytime
  • Lubricating ointment at night
  • Tape eyelids closed if necessary for complete protection

Additional Management

• Physical therapy may benefit patients with more severe paralysis 2
• Patients with persistent dysphagia (beyond 3 months) should be referred to a facial nerve specialist 1

Special Populations

• Children and pregnant women have higher spontaneous recovery rates (up to 90%) 2
• Elderly patients may particularly benefit from treatment, with one study showing 100% recovery in treated patients over 60 years compared to only 42% in untreated controls 5

Prognosis

• Overall prognosis is good with more than two-thirds of untreated patients experiencing complete spontaneous recovery 2
• Early treatment with corticosteroids significantly improves recovery rates 3
• Delay or lack of treatment may increase risk of facial impairment and negatively impact quality of life 6

Common Pitfalls

• Delaying corticosteroid therapy beyond 72 hours after symptom onset reduces efficacy
• Relying solely on antiviral therapy without corticosteroids
• Neglecting eye protection measures in patients with incomplete eye closure
• Failing to recognize Bell's palsy mimics that require different management (stroke, tumor, Lyme disease)
• Not considering higher corticosteroid doses for severe cases