Treatment of 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 significantly improved recovery rates. 1, 2
Diagnostic Approach
- Bell's palsy is characterized by acute onset of unilateral facial weakness/paralysis involving the forehead in a lower motor neuron pattern
- Diagnosis is clinical and does not require routine laboratory testing or imaging 1, 2
- Targeted diagnostic testing should only be performed based on clinical suspicion of other etiologies
Treatment Algorithm
First-Line Treatment
- Oral corticosteroids: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 1, 2
- Should be started as early as possible for maximum benefit
- High-quality evidence demonstrates significantly improved recovery rates
Optional Additional Treatment
- Antiviral therapy: May be considered in combination with corticosteroids 1, 3
- Valacyclovir (1 g three times daily for 7 days) OR
- Acyclovir (400 mg five times daily for 10 days)
- Evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
- May reduce rates of synkinesis (misdirected regrowth of facial nerve fibers) 2
- Antiviral treatment alone is ineffective and not recommended 2, 4
Critical Eye Protection Measures
- For patients with impaired eye closure:
- Artificial tears during the day
- Lubricating ointment at night
- Taping eyelids closed if necessary 1
- These measures prevent corneal damage and are essential for patients who cannot fully close their affected eye
Rehabilitation Options
- Physical therapy: May be beneficial for patients with more severe paralysis 2
- Referral to facial nerve specialist: Indicated if swallowing difficulties persist beyond 3 months 1
Special Populations and Prognosis
- Children and pregnant women have higher spontaneous recovery rates (up to 90%) 2
- Overall prognosis is generally good with more than two-thirds of patients experiencing complete spontaneous recovery 2
- Early treatment with corticosteroids significantly improves outcomes and reduces risk of long-term facial paresis 4
Important Clinical Considerations
- Treatment should be initiated as soon as possible after symptom onset for maximum effectiveness
- The number needed to treat (NNT) with prednisolone to achieve complete recovery is approximately 7.8 (95% CI 5.9-13.7) 4
- When combining valacyclovir with prednisolone, the NNT compared to prednisolone alone is 14.8 (95% CI 9.1-744.8), indicating minimal additional benefit 4
- Monitor patients for potential side effects of corticosteroids, particularly in those with diabetes, hypertension, or other comorbidities