What is the 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

• Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Corticosteroid treatment significantly improves facial nerve recovery, 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
• Treatment should be initiated as soon as possible, ideally within 72 hours of symptom onset for maximum effectiveness 1, 2

Eye Protection

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2
• Use lubricating ophthalmic drops frequently throughout the day 1
• Apply ophthalmic ointments for more effective moisture retention, particularly at night 1
• Consider moisture chambers using polyethylene covers for nighttime protection 1
• Use eye patching or taping with caution, particularly at night 1
• Recommend sunglasses for outdoor protection against foreign particles 1

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed for Bell's palsy 1, 2, 4
• 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%) 1, 2
• When used, recommended antiviral regimens include valacyclovir (1 g three times daily for seven days) or acyclovir (400 mg five times daily for 10 days) 4, 5

Special Populations

Children

• Children have better prognosis with higher rates of spontaneous recovery 1, 4
• Evidence for steroid use in children is less conclusive 1

Pregnant Women

• Treat pregnant women with oral corticosteroids on an individualized basis, carefully weighing benefits and risks 1

Follow-up and Monitoring

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

Management of Complications

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis 6, 4, 7
• For persistent lagophthalmos beyond 3 months, consider referral to a facial nerve specialist or ophthalmologist 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
• Failing to rule out other causes of facial weakness before diagnosing Bell's palsy 1, 2
• Improper eye taping technique can cause corneal abrasion 1
• Delaying specialist referral for patients with severe or persistent symptoms 1