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 first-line treatment for all patients 16 years and older with Bell's palsy. 1, 2

First-Line Treatment

• Prescribe a 10-day course of oral steroids with at least 5 days at high dose, using either:

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

• Early treatment with prednisolone significantly improves complete recovery rates (83% at 3 months and 94.4% at 9 months) compared to placebo (63.6% at 3 months and 81.6% at 9 months) 3

• Treatment must be initiated within 72 hours of symptom onset for maximum effectiveness; benefit after this window is less clear 4, 2

Combination Therapy Considerations

• Antiviral monotherapy should NOT be prescribed as it is ineffective 2, 1

• Combination therapy with oral antivirals and corticosteroids may be considered as an option within 72 hours of symptom onset 1

• Some evidence suggests higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2

• When 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 5

Eye Protection

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

• Eye protection measures include:

  • Lubricating ophthalmic drops for daytime protection
  • Ophthalmic ointments for nighttime protection
  • Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 4

Special Populations

• Children: Evidence for steroid use is less conclusive as children show higher rates of spontaneous recovery (up to 90%) than adults 1, 5

• Elderly patients: May particularly benefit from treatment, with one study showing 100% complete recovery in treated patients over 60 years compared to 42% in untreated controls 6

Follow-up and Monitoring

• 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 2, 1

• Physical therapy may be beneficial for patients with more severe paralysis and developing synkinesis, though evidence for specific protocols is limited 7, 5

Emerging Evidence

• Recent meta-analysis suggests high-dose corticosteroids (≥80 mg) may be more effective than standard doses (40-60 mg), showing significant decrease in non-recovery at 6 months follow-up 8

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours, which reduces effectiveness 4, 1

• Using antiviral therapy alone, which is ineffective 2, 1

• Failing to provide adequate eye protection for patients with impaired eye closure 4, 2

• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 2

• Performing unnecessary laboratory testing and imaging for typical presentations of Bell's palsy 1, 2