What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset as the primary treatment for Bell's palsy in patients 16 years and older. 1

First-Line Treatment

• Oral steroids should be administered within 72 hours of symptom onset in a 10-day course with at least 5 days at high dose 1:

  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

• Steroids significantly improve recovery rates:

  • 83% recovery at 3 months with prednisolone vs. 63.6% without 1, 3
  • 94.4% recovery at 9 months with prednisolone vs. 81.6% without 1, 4
  • Number needed to treat (NNT) for one additional complete recovery is 6 4

Antiviral Therapy

• Antiviral monotherapy should NOT be prescribed for Bell's palsy 1
• Combination therapy (antivirals plus steroids) may be offered as an option within 72 hours of symptom onset 1
• Potential antiviral options when used with steroids:
  • Valacyclovir 1 g three times daily for 7 days 2
  • Acyclovir 400 mg five times daily for 10 days 2

Eye Protection

• Eye protection should be implemented for all patients with impaired eye closure 1
• This is crucial to prevent corneal damage and maintain eye health during recovery 1

Diagnostic Approach

• Diagnosis is based on clinical presentation of acute unilateral facial weakness/paralysis developing in less than 72 hours 1
• Routine laboratory testing is NOT recommended 1
• Routine diagnostic imaging is NOT recommended 1

Special Populations

• For children: Evidence for steroid use is less conclusive, but may be considered given the presumed similar disease process 1
• For pregnant women: Recovery rates are higher (up to 90%) even without treatment 2

Follow-up and Referral

• Patients should be reassessed or referred to a facial nerve specialist if 1:
  1. New or worsening neurologic findings develop at any point
  2. Ocular symptoms develop at any point
  3. Incomplete facial recovery 3 months after symptom onset

Electrodiagnostic Testing

• Should NOT be performed in patients with incomplete facial paralysis 1
• May be offered as an option for patients with complete facial paralysis 1

Other Therapies

• No recommendations can be made regarding:
  • Surgical decompression 1
  • Acupuncture 1
  • Physical therapy, though it may be beneficial in patients with more severe paralysis 1, 2

Common Pitfalls to Avoid

• Delaying steroid treatment beyond 72 hours reduces effectiveness 1
• Using antiviral therapy alone provides no benefit 1, 3
• Failing to provide adequate eye protection can lead to corneal damage 1
• Missing atypical features that suggest alternative diagnoses (bilateral involvement, slow progression, or other neurologic symptoms) 1