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

First-Line Treatment

• Prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 2, 3
• Early corticosteroid treatment significantly improves recovery rates (83% at 3 months with prednisolone vs 63.6% with placebo) 2, 4
• Long-term outcomes are also better with early steroid treatment (94.4% recovery at 9 months with prednisolone vs 81.6% with placebo) 2, 4

Timing of Treatment

• The 72-hour window is critical as clinical trials demonstrating efficacy specifically enrolled patients within this timeframe 1, 3
• Treatment initiated within 48 hours shows significantly higher complete recovery rates compared to later administration 5
• The benefit of treatment after 72 hours is less clear and not supported by high-quality evidence 1

Antiviral Therapy

• Antiviral therapy alone should NOT be prescribed as it is ineffective 2, 3, 6
• Combination therapy with oral antivirals and corticosteroids may be offered as an option within 72 hours of symptom onset 2, 3
• Some evidence shows slightly higher recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2, 3

Eye Protection

• Eye protection is essential for patients with impaired eye closure to prevent corneal damage 1, 2
• Implement the following measures:
  • Lubricating ophthalmic drops for daytime protection 1, 2
  • Ophthalmic ointments for nighttime protection 1, 2
  • Consider moisture chambers, eye patching/taping, and sunglasses as appropriate 1, 2

Follow-up and Monitoring

• Monitor for recovery, with most patients showing signs of improvement within 2-3 weeks 1, 2
• Refer to a specialist if:
  • New or worsening neurologic findings develop 1, 2
  • Ocular symptoms develop 1, 2
  • Incomplete facial recovery persists 3 months after initial symptom onset 1, 2, 3

Prognosis

• Approximately 70% of Bell's palsy patients with complete paralysis recover facial function completely within 6 months even without treatment 1, 2, 7
• Patients with incomplete paralysis have higher recovery rates, up to 94% 1, 2
• Children have better prognosis with higher rates of spontaneous recovery than adults 1, 2

Special Populations

• For pregnant women, treatment should be individualized with careful assessment of benefits and risks 1, 2
• Children have higher rates of spontaneous recovery, but evidence for steroid use in children is less conclusive 2, 3

Common Pitfalls to Avoid

• Starting steroid treatment beyond the 72-hour window provides minimal benefit and exposes patients to medication risks 1, 3
• Using antiviral therapy alone is ineffective and not recommended 1, 2, 3
• Failing to provide adequate eye protection for patients with impaired eye closure can lead to corneal damage 1, 2
• Not referring patients with incomplete recovery after 3 months for specialist evaluation 1, 2
• Routine laboratory testing and imaging are not required for typical presentations of Bell's palsy 2, 3