What is the initial treatment for Bell's palsy?

Initial Treatment for Bell's Palsy

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, 3

Recommended Steroid Regimen

• The recommended corticosteroid regimen is either prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper 2, 3
• Treatment should be initiated as soon as possible, ideally within 72 hours of symptom onset, as effectiveness decreases beyond this timeframe 1, 2
• Corticosteroid treatment significantly improves recovery rates: 83% at 3 months and 94.4% at 9 months with prednisolone versus 63.6% at 3 months and 81.6% at 9 months without prednisolone 1, 4
• The number needed to treat (NNT) to achieve one additional complete recovery with corticosteroids is 6 5

Antiviral Therapy Considerations

• Antiviral monotherapy is NOT recommended for Bell's palsy treatment 2, 3, 6
• Combination therapy with oral antivirals and corticosteroids may be considered as an option within 72 hours of symptom onset 3
• Evidence for combination therapy is mixed - some studies show higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 3, while others found no additional benefit 4, 5

Special Populations

• For children with Bell's palsy, evidence for steroid use is less conclusive as they show higher spontaneous recovery rates than adults 1, 2, 3
• Pregnant women also have higher spontaneous recovery rates (up to 90%) 6
• Elderly patients (over 60 years) may particularly benefit from treatment, with one study showing 100% complete recovery in treated patients versus only 42% in untreated controls 7

Eye Protection

• Eye protection is strongly recommended for all Bell's palsy patients with impaired eye closure to prevent corneal damage 2, 3
• This includes artificial tears during the day and eye ointment at night 2

Follow-up Recommendations

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

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours, which reduces effectiveness 1, 3
• Using antiviral therapy alone, which is ineffective 2, 3, 6
• Failing to provide adequate eye protection for patients with impaired eye closure 2, 3
• Ordering unnecessary laboratory tests or imaging for typical presentations 2, 3
• Missing atypical features that would warrant imaging or further investigation (e.g., trauma to temporal bone, history of tumor, involvement of other cranial nerves) 1, 2