What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Oral corticosteroids should be prescribed within 72 hours of symptom onset as the first-line treatment for Bell's palsy in patients 16 years and older. 1, 2

Initial Assessment

• Diagnosis requires excluding other causes of facial weakness through history and physical examination 1
• Bell's palsy is defined as acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without identifiable cause 1
• Routine laboratory testing and diagnostic imaging are not recommended for typical presentations 1, 2

First-Line Treatment

• Corticosteroid regimen options:
  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Treatment should be initiated within 72 hours of symptom onset for maximum effectiveness 1, 3
• Early treatment (within 48 hours) results in significantly higher complete recovery rates compared to delayed treatment 4

Antiviral Therapy

• Antiviral monotherapy should not be prescribed alone as it shows no benefit over placebo 1, 5
• Combination therapy (antivirals plus corticosteroids) may be offered as an option within 72 hours of symptom onset 1, 2
• Some evidence suggests combination therapy may provide slightly higher recovery rates (96.5%) compared to steroids alone (89.7%) 1
• When used, appropriate antiviral options include valacyclovir (1g three times daily for 7 days) or acyclovir (400mg five times daily for 10 days) 5, 6

Eye Protection

• Eye protection must be implemented for patients with impaired eye closure to prevent corneal damage 1, 2
• Options include:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Taping the eye closed
  • Moisture chambers

Special Populations

• Children: Evidence for steroid use is less conclusive as children show higher spontaneous recovery rates than adults 1, 2
• Elderly patients: May particularly benefit from combination therapy, with one study showing 100% recovery in treated patients over 60 years versus only 42% in untreated controls 6

Follow-up and Monitoring

• Patients should be reassessed or referred to a facial nerve specialist if:
  • New or worsening neurologic findings develop at any point
  • Ocular symptoms develop at any point
  • Incomplete facial recovery persists 3 months after symptom onset 1, 2
• Electrodiagnostic testing is not recommended for patients with incomplete facial paralysis 1
• Electrodiagnostic testing may be offered as an option for patients with complete facial paralysis 1

Other Therapies

• No recommendations can be made regarding:
  • Surgical decompression
  • Acupuncture
  • Physical therapy 1, 7
• However, physical therapy may be beneficial in patients with more severe paralysis 5

Common Pitfalls

• Delaying treatment beyond 72 hours significantly reduces effectiveness 2, 4
• Using antiviral therapy alone is ineffective and not recommended 1, 5
• Failing to provide adequate eye protection can lead to corneal damage 2
• Missing other causes of facial weakness by not performing a thorough assessment 1