What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

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

First-Line Treatment

• Corticosteroid therapy:
  • Prednisolone 50-60mg daily for 5 days followed by a 5-day taper 1, 2
  • Should be started as early as possible, ideally within 72 hours of symptom onset 3
  • High-quality evidence shows significantly improved recovery rates with early steroid administration 1
  • Studies demonstrate that prednisolone shortens time to complete recovery (HR 1.40,95% CI 1.18-1.64) 4
  • Recovery rates increase from approximately 70% with no treatment to 83-94% with prednisolone 3

Antiviral Therapy

• Antiviral agents (optional):
  • May be considered in combination with corticosteroids 1
  • Options include valacyclovir (1g three times daily for 7 days) or acyclovir (400mg five times daily for 10 days) 2
  • Evidence for antiviral therapy alone is insufficient, and it is not recommended as monotherapy 1, 2, 3
  • Some studies suggest combination therapy may reduce rates of synkinesis (involuntary co-contraction of facial muscles) 2
  • The most recent high-quality evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1

Critical Eye Protection

• Eye protection is crucial for patients with impaired eye closure:
  • Artificial tears during daytime
  • Lubricating ointment at night
  • Taping eyelids closed if necessary to prevent corneal damage 1
  • Failure to protect the eye can lead to corneal ulceration, a serious complication

Additional Management

• Physical therapy may be beneficial for patients with more severe paralysis 2
• Supportive care for patients with dysphagia
• Referral to facial nerve specialist if swallowing difficulties persist beyond 3 months 1

Special Populations

• Elderly patients (>60 years):

  • May particularly benefit from combination therapy with corticosteroids and antivirals
  • One study showed 100% recovery in elderly patients treated with valacyclovir and prednisone versus only 42% in untreated controls 5

• Children and pregnant women:

  • Have higher spontaneous recovery rates (up to 90%) even without treatment 2
  • Treatment decisions should still follow standard guidelines but with consideration of risk-benefit ratio

Common Pitfalls

1. Delayed treatment - Corticosteroids should be initiated within 72 hours of symptom onset for maximum benefit
2. Neglecting eye protection - Can lead to serious corneal complications
3. Using antivirals alone - Not effective as monotherapy
4. Misdiagnosis - Ensure proper diagnosis of Bell's palsy by excluding other causes of facial weakness
5. Unnecessary imaging - Neuroimaging should not be performed routinely but reserved for specific indications 1