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 for all patients 16 years and older with Bell's palsy as the first-line treatment. 1, 2, 3

First-Line Treatment

• The recommended corticosteroid regimen is prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2, 3
• Treatment with corticosteroids significantly improves recovery rates: 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 3, 4
• The number needed to treat (NNT) to achieve one additional complete recovery is 6 5
• Corticosteroids are only effective when started within the 72-hour window after symptom onset 1, 2, 3

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed for Bell's palsy as it is ineffective 1, 2, 3, 6
• Combination therapy with oral antivirals and corticosteroids within 72 hours may be considered as an option 2, 3
• Some evidence shows slightly higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2
• Recommended antiviral regimens when used in combination include valacyclovir (1 g three times daily for 7 days) or acyclovir (400 mg five times daily for 10 days) 6

Eye Protection (Critical)

• Implement eye protection for all patients with impaired eye closure to prevent corneal damage 1, 2, 3
• Use lubricating ophthalmic drops for daytime protection 1, 3
• Apply ophthalmic ointments for nighttime protection 1, 3
• Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 1, 3
• Failure to provide adequate eye protection can lead to permanent corneal damage 1, 3

Treatment Timing Considerations

• The 72-hour window for starting corticosteroids is critical - treatment efficacy significantly decreases after this period 1, 2, 3
• Patients treated with prednisolone within 24 hours and 25-48 hours have significantly higher complete recovery rates (66% and 76% respectively) compared to no prednisolone (51% and 58%) 7
• For patients presenting after 72 hours, focus on eye protection rather than corticosteroids 1

Special Populations

• Children have better prognosis with higher rates of spontaneous recovery (up to 90%) 1, 3, 6
• Evidence for corticosteroid use in children is less conclusive 2, 3
• Patients aged 40 years or older benefit significantly more from prednisolone treatment than younger patients 7
• Pregnant women should receive corticosteroids within 72 hours with careful assessment of benefits and risks 3

Follow-up and Monitoring

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset 1, 3
• Complete recovery typically occurs within 3-4 months for most patients 3
• Reassess or refer to a facial nerve specialist if 1, 2, 3:
  • New or worsening neurologic findings develop
  • Ocular symptoms develop
  • Incomplete facial recovery persists 3 months after initial symptom onset

Recovery Expectations

• Approximately 70% of patients with complete paralysis recover facial function completely within 6 months even without treatment 1, 3
• Patients with incomplete paralysis have higher recovery rates, up to 94% 1, 3
• About 30% of patients may experience permanent facial weakness with muscle contractures 3

Common Pitfalls to Avoid

• Starting steroid treatment beyond the 72-hour window provides minimal benefit and exposes patients to medication risks 1, 2
• Using antiviral therapy alone is ineffective and not recommended 1, 2, 3, 6
• Failing to provide adequate eye protection for patients with impaired eye closure 1, 3
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 3