What is the initial treatment for a patient with Bell's palsy?

Initial Treatment for Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy. 1

First-Line Treatment

• Prescribe oral corticosteroids within 72 hours of symptom onset for patients 16 years and older 1, 2
• Recommended regimen: prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 3
• Strong evidence supports corticosteroid use, with studies showing 83% recovery at 3 months with prednisolone vs 63.6% with placebo 2
• The 72-hour window is critical - treatment efficacy significantly decreases after this timeframe 4

Combination Therapy Considerations

• Antiviral monotherapy should NOT be prescribed as it is ineffective 1, 2
• Consider combination therapy with oral antivirals and corticosteroids within 72 hours of symptom onset 1
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 1, 5
• If using combination therapy, valacyclovir (1 g three times daily for 7 days) or acyclovir (400 mg five times daily for 10 days) can be added to the steroid regimen 3, 5

Eye Protection (Essential Component)

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2
• Use lubricating ophthalmic drops for daytime protection 4, 2
• Apply ophthalmic ointments for nighttime protection 4, 2
• Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 4, 2

Special Populations

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) 2, 3
• Evidence for steroid use in children is less conclusive 1, 2
• For pregnant women, treatment should be individualized with careful assessment of benefits and risks 2

Follow-up and Monitoring

• Reassess or refer to a facial nerve specialist if:
  • New or worsening neurologic findings develop 1, 4
  • Ocular symptoms develop 1, 4
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 4

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness of therapy 1, 4
• Using antiviral therapy alone is ineffective and not recommended 1, 2
• Failing to rule out other causes of facial weakness before diagnosing Bell's palsy 1, 2
• Not providing adequate eye protection for patients with impaired eye closure 1, 2
• Routine laboratory testing and imaging are not required for typical presentations 1, 2

Recovery Expectations

• Approximately 70% of patients with complete paralysis recover facial function completely within 6 months even without treatment 4, 2
• Patients with incomplete paralysis have higher recovery rates, up to 94% 4, 2
• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 4, 2