What is the recommended initial treatment for Bell's palsy?

Initial Treatment for Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for patients 16 years and older with Bell's palsy. 1, 2

First-Line Treatment Regimen

• A 10-day course of oral steroids with at least 5 days at high dose is recommended using either:
  • 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 as soon as possible, ideally within 72 hours of symptom onset for maximum effectiveness 1, 2
• Randomized controlled trials have demonstrated that patients treated with prednisolone had significantly higher recovery rates (83% at 3 months, 94.4% at 9 months) compared to those receiving placebo (63.6% at 3 months, 81.6% at 9 months) 1, 3

Antiviral Therapy Considerations

• Antiviral monotherapy should NOT be prescribed for patients with new-onset Bell's palsy 1, 2
• Combination therapy with oral antivirals plus steroids may be offered as an option within 72 hours of symptom onset 1, 2
• If considering combination therapy, recommended antiviral regimens include:
  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 4
• Evidence for combination therapy shows mixed results:
  • Some studies show higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2
  • However, other high-quality trials found no significant benefit from adding antivirals to steroid treatment 3

Eye Protection

• Implement eye protection for all Bell's palsy patients with impaired eye closure to prevent corneal damage 1, 2
• Eye protection measures may include:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Eye patch or tape for complete closure when necessary 2

Special Populations

• For children: Evidence for steroid use is less conclusive as children show higher rates of spontaneous recovery (up to 90%) than adults 1, 2, 4
• For pregnant women: Similar high spontaneous recovery rates (up to 90%) have been observed 4
• For elderly patients: Treatment with steroids appears particularly beneficial, with one study showing 100% recovery in treated patients over 60 years compared to only 42% in untreated controls 5

Follow-up Recommendations

• Reassess or refer 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 initial symptom onset 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours, which reduces effectiveness 2
• Using antiviral therapy alone, which is ineffective 1, 2, 4
• Failing to provide adequate eye protection, which can lead to corneal damage 2
• Ordering unnecessary laboratory tests or imaging studies for typical presentations 1, 2
• Missing other causes of facial weakness by not performing a thorough assessment 1, 2

Treatment Algorithm

1. Confirm diagnosis of Bell's palsy (acute unilateral facial weakness/paralysis within 72 hours without identifiable cause) 1
2. Start oral corticosteroids immediately (within 72 hours of symptom onset) 1
3. Consider adding antiviral therapy in select cases (especially if complete paralysis or suspicion of herpes zoster) 1, 2
4. Implement eye protection measures for all patients with impaired eye closure 1, 2
5. Schedule follow-up at 3 months to assess recovery 1, 2
6. Refer to facial nerve specialist if incomplete recovery at 3 months 1, 2