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 first-line treatment for Bell's palsy in patients 16 years and older. 1

First-Line Treatment

• Prescribe oral corticosteroids within 72 hours of symptom onset for patients 16 years and older 1, 2
• Recommended regimens:
  • Prednisolone 50 mg daily for 10 days, OR
  • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Strong evidence supports corticosteroid use, with 83% recovery at 3 months with prednisolone vs 63.6% with placebo, and 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1, 3
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 4

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed for Bell's palsy 1, 2
• Combination therapy with oral antivirals and corticosteroids may be offered within 72 hours of symptom onset as an option 1, 2
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2, 5
• However, other studies found no additional benefit of acyclovir when combined with prednisolone 3, 4

Eye Protection

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2
• Recommended eye protection methods include:
  • Lubricating ophthalmic drops used frequently throughout the day 1
  • Ophthalmic ointments, particularly at night (may cause temporary vision blurring) 1
  • Moisture chambers using polyethylene covers for nighttime protection 1
  • Eye patching or taping with careful instruction on proper technique 1
  • Sunglasses for outdoor protection 1

Special Populations

Children

• Children have better prognosis with higher rates of spontaneous recovery than adults 1, 6
• Evidence for steroid use in children is less conclusive 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours of symptom onset, with careful individualized assessment of benefits and risks 1
• Pregnant women have up to 90% complete spontaneous recovery rate 6

Follow-up and Referral

• Reassess or refer to a facial nerve specialist if:
  • New or worsening neurologic findings develop at any point 1, 2
  • Ocular symptoms develop at any point 1, 2
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 2
• MRI with and without contrast is the imaging test of choice when indicated (atypical presentations, no recovery after 3 months, worsening symptoms) 1

Recovery Timeline

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1
• Complete recovery typically occurs within 3-4 months for most patients 1
• Approximately 70% of patients with complete paralysis recover facial function completely within 6 months 1
• Patients with incomplete paralysis have higher recovery rates, up to 94% 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 1, 2
• Using antiviral therapy alone is ineffective 1, 2, 3
• Failing to provide adequate eye protection for patients with impaired eye closure 1
• Improper eye taping technique can cause corneal abrasion 1
• Delaying specialist referral for patients with severe or persistent symptoms 1
• Failing to rule out other causes of facial weakness before diagnosing Bell's palsy 1, 2

Prevention of Synkinesis

• Early treatment with corticosteroids helps prevent synkinesis (misdirected regrowth of facial nerve fibers) 7, 6
• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis 7, 6