Medication for Bell's Palsy
Oral corticosteroids are the first-line treatment for Bell's palsy and should be prescribed within 72 hours of symptom onset for patients 16 years and older to significantly improve facial nerve recovery. 1
Primary Treatment Recommendations
- Prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper is the recommended corticosteroid regimen 2, 1
- Treatment should be initiated within 72 hours of symptom onset for maximum effectiveness, as studies show significantly higher recovery rates when started within this timeframe 1, 3
- Strong evidence supports corticosteroid use, with studies showing 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 2, 4
Antiviral Therapy Considerations
- Antiviral monotherapy should NOT be prescribed for Bell's palsy as it is ineffective 2, 1
- Combination therapy with oral antiviral agents (such as valacyclovir or acyclovir) and corticosteroids may be considered as an option within 72 hours of symptom onset 2, 5
- Some evidence shows slightly higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), though the benefit is modest 2, 6
- Recommended antiviral regimens when used in combination with corticosteroids include valacyclovir (1 g three times daily for 7 days) or acyclovir (400 mg five times daily for 10 days) 5, 6
Special Population Considerations
Children
- Children with Bell's palsy have better prognosis with higher rates of spontaneous recovery than adults 2, 1
- Evidence for steroid use in children is less conclusive, but oral steroids may be considered based on the presumed similar disease process as in adults 2, 1
Elderly
- Patients over 60 years of age may particularly benefit from treatment, with studies showing 100% complete recovery in treated elderly patients compared to only 42% in untreated controls 6
Pregnancy
- Pregnant women with Bell's palsy should be treated with oral corticosteroids within 72 hours of symptom onset, with careful assessment of benefits and risks 1
Adjunctive Treatments
- Eye protection is essential for patients with impaired eye closure to prevent corneal damage 1, 7
- Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 8, 5
Follow-up Recommendations
- Patients should be reassessed or referred to a facial nerve specialist if they have 1, 7:
- New or worsening neurologic findings at any point
- Ocular symptoms developing at any point
- Incomplete facial recovery 3 months after initial symptom onset
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours reduces effectiveness of therapy 1, 3
- Using antiviral therapy alone is ineffective and not recommended 2, 1
- Failing to provide adequate eye protection for patients with impaired eye closure, which can lead to corneal damage 1, 7
- Not considering drug interactions with corticosteroids, particularly in patients on anticoagulants, antidiabetics, or those with infections 9