What is the recommended treatment for Bell's palsy?

Treatment for Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset as first-line treatment for Bell's palsy in patients 16 years and older. 1, 2

First-Line Treatment Algorithm

1. Timing of Treatment:

   • Initiate treatment within 72 hours of symptom onset for maximum effectiveness 1, 3
   • The benefit of treatment after 72 hours is less clear and not supported by high-quality evidence 3

2. Recommended Corticosteroid Regimens:

   • Prednisolone 50 mg daily for 10 days, OR
   • Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

3. Antiviral Considerations:

   • Do not prescribe antiviral therapy alone (strong recommendation against) 1, 2
   • May consider adding antiviral therapy to corticosteroids within 72 hours of symptom onset as an option 1, 2
   • If using combination therapy, recommended antivirals include:
     • Valacyclovir 1 g three times daily for 7 days, OR
     • Acyclovir 400 mg five times daily for 10 days 4

Special Populations

1. Children:

   • Evidence for steroid use in children is less conclusive 1, 2
   • Children show higher rates of spontaneous recovery than adults 1, 3
   • Consider involving caregivers in the decision-making process 1

2. Pregnant Women:

   • Treatment should be carefully considered weighing benefits and risks 3
   • Pregnant women have higher recovery rates (up to 90%) even without treatment 4

Eye Protection Measures

• Implement eye protection for all patients with impaired eye closure 1, 3
• Use lubricating ophthalmic drops for daytime protection 3
• Apply ophthalmic ointments for nighttime protection 3
• Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 3

Follow-up and Monitoring

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 3
• Reassess or refer to a facial nerve specialist if:
  • New or worsening neurologic findings develop at any point
  • Ocular symptoms develop at any point
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 2

Prognosis

• Approximately 70% of Bell's palsy patients with complete paralysis recover facial function completely within 6 months even without treatment 3
• Patients with incomplete paralysis have higher recovery rates, up to 94% 3
• Studies show 83% recovery at 3 months with prednisolone compared to 63.6% with placebo 1, 3
• Combination therapy with antivirals may reduce rates of synkinesis (involuntary co-contraction of facial muscles) 4

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness 3, 2
• Using antiviral therapy alone is ineffective 1, 2
• Failing to provide adequate eye protection can lead to corneal damage 3, 2
• Routine laboratory testing and imaging are not required for typical presentations of Bell's palsy 2
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 3

Emerging Research

• Recent meta-analysis suggests high-dose corticosteroids (≥80 mg) may be more effective than standard doses (40-60 mg) for Bell's palsy treatment, though more robust research is needed 5
• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 6, 4