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, 2

First-Line Treatment

• Recommended corticosteroid regimens include:

  • 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

Eye Protection

• Eye protection is essential for all patients with impaired eye closure to prevent corneal damage 1, 2

• Recommended eye protection methods include:

  • Frequent lubricating ophthalmic drops 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

Combination Therapy Considerations

• Antiviral therapy alone should NOT be prescribed for Bell's palsy 1, 2, 5

• Combination therapy with oral antivirals and corticosteroids may be offered within 72 hours of symptom onset 1, 2

• Some evidence shows slightly higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), though the benefit is small 2, 6

• If using antivirals, options include:

  • Valacyclovir 1 g three times daily for 7 days, OR
  • Acyclovir 400 mg five times daily for 10 days 5, 6

Special Populations

• Children have better prognosis with higher rates of spontaneous recovery (up to 90%) 1, 5

• Pregnant women should be treated with oral corticosteroids within 72 hours, with individualized assessment of benefits and risks 1

• Elderly patients may particularly benefit from treatment, with one study showing 100% recovery in treated patients over 60 years versus 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
  • Ocular symptoms develop
  • Incomplete facial recovery persists 3 months after symptom onset 1, 7, 2

• MRI with and without contrast is the imaging test of choice when indicated (for atypical presentations or no recovery after 3 months) 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 can lead to corneal damage 1

• Routine laboratory testing and imaging are not required for typical presentations 1, 2

• Improper eye taping technique can cause corneal abrasion 1