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 prednisone 50-60 mg daily for 5 days followed by a 5-day taper. 1, 2

Diagnostic Approach

Bell's palsy should be suspected in patients with:

• Acute onset of unilateral facial weakness/paralysis
• Involvement of the forehead
• Absence of other neurological abnormalities

Laboratory testing and imaging are not routinely required for diagnosis of typical Bell's palsy 2.

Treatment Algorithm

First-Line Treatment

• Corticosteroids: Prednisone 50-60 mg daily for 5 days followed by a 5-day taper 1, 2
  • Should be initiated as early as possible (ideally within 72 hours of symptom onset)
  • High-quality evidence shows significantly improved recovery rates with early steroid administration 1
  • Treatment with prednisolone increases 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: May be considered in combination with steroids 1
  • Options include:
    • Valacyclovir 1 g three times daily for 7 days 2, 4
    • Acyclovir 400 mg five times daily for 10 days 2
  • Evidence shows minimal additional benefit when combined with steroids (RR 0.75,95% CI 0.56-1.00) 1
  • Antivirals alone are ineffective and not recommended 2, 3
  • May be particularly beneficial in reducing rates of synkinesis (involuntary co-contraction of facial muscles) 2

Eye Protection (Critical)

For patients with impaired eye closure:

• Artificial tears during the day
• Lubricating ointment at night
• Taping eyelids closed if necessary 1

Additional Interventions

• 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: Combination therapy with valacyclovir and prednisone may be particularly beneficial, with one study showing 100% recovery rate in patients over 60 years compared to only 42% in untreated controls 5
• Children and pregnant women: Generally have better prognosis with up to 90% complete spontaneous recovery 2

Prognosis

• Overall prognosis is good
• More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 2
• Early treatment with corticosteroids significantly improves recovery rates 3

Common Pitfalls to Avoid

1. Delayed treatment: Early initiation of corticosteroids (within 72 hours) is crucial for optimal outcomes
2. Using antivirals alone: Not effective as monotherapy
3. Neglecting eye protection: Can lead to corneal damage in patients with incomplete eye closure
4. Missing other causes of facial weakness: Ensure thorough evaluation to rule out other etiologies
5. Inadequate follow-up: Patients with persistent symptoms beyond 3 months should be referred to specialists