What is the treatment for Bell's palsy?

Treatment for Bell's Palsy

Start oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy—this is the single most important intervention that significantly improves complete recovery rates. 1, 2

First-Line Treatment: Corticosteroids

Prescribe one of these regimens immediately:

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

The evidence is compelling: Corticosteroids increase complete recovery at 3 months from 63.6% to 83.0%, and at 9 months from 81.6% to 94.4%. 2, 3 This represents a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery based on high-quality randomized controlled trial data. 1, 2

Timing Is Critical

• Treatment must begin within 72 hours of symptom onset to be effective. 1, 2
• Delaying beyond this window significantly reduces therapeutic benefit. 1

Combination Therapy: Corticosteroids Plus Antivirals

Consider adding antiviral therapy to corticosteroids within 72 hours of symptom onset, particularly for patients seeking maximal recovery potential. 1, 2

Recommended antiviral regimens:

• Valacyclovir 1 g three times daily for 7 days, OR 4
• Acyclovir 400 mg five times daily for 10 days 4

The evidence shows modest additional benefit: Combination therapy achieves 96.5% complete recovery compared to 89.7% with steroids alone, and may reduce synkinesis rates. 1, 4 While the largest trial showed no significant benefit of adding acyclovir to prednisolone, 3 smaller studies demonstrate improved outcomes with combination therapy, especially in elderly patients. 5, 6

Critical Warning

Never prescribe antiviral monotherapy—it is ineffective and not recommended by the American Academy of Otolaryngology-Head and Neck Surgery. 1, 2, 4

Essential Eye Protection

Implement eye protection immediately for all patients with impaired eye closure to prevent potentially devastating corneal damage. 1, 2

Daytime protection:

• Lubricating ophthalmic drops frequently throughout the day 1, 2
• Sunglasses outdoors for protection against particles and irritants 1, 2

Nighttime protection (most critical):

• Ophthalmic ointments before sleep for superior moisture retention 1, 2
• Eye patching or taping (with careful instruction on proper technique to avoid corneal abrasion) 1, 2
• Moisture chambers using polyethylene covers 2

Refer immediately to ophthalmology if:

• Eye pain, vision changes, redness, or discharge develop 2
• Severe lagophthalmos is present 2

Special Populations

Children

• Children have better prognosis with up to 90% spontaneous recovery rates. 4
• Evidence for corticosteroid benefit in children is less conclusive, but consider treatment on an individualized basis with caregiver involvement. 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 2
• Combination therapy with antivirals may be considered on an individualized basis. 2

Follow-Up and Monitoring

Reassess or refer to a facial nerve specialist if:

• New or worsening neurologic findings develop at any point 1, 2
• Ocular symptoms develop 1, 2
• Incomplete facial recovery persists 3 months after symptom onset 1, 2

At 3-month follow-up with incomplete recovery:

• Consider MRI with and without contrast to exclude other causes 2
• Refer to facial nerve specialist for evaluation 1, 2

Diagnostic Testing

Do NOT order routine laboratory testing or imaging for typical Bell's palsy presentations. 1, 2 The diagnosis is clinical, based on acute unilateral facial weakness involving the forehead with onset under 72 hours and no identifiable cause. 2

Order MRI with and without contrast only if:

• Atypical features present (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) 2
• Second paralysis on same side 2
• No recovery after 3 months 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours—this is the most common error that reduces treatment effectiveness. 1
• Prescribing antivirals alone—completely ineffective without corticosteroids. 1, 2, 4
• Failing to provide adequate eye protection—can lead to permanent corneal damage. 1
• Improper eye taping technique—can cause corneal abrasion; patients need careful instruction. 2
• Not ruling out other causes—perform thorough history and physical examination to exclude identifiable causes before diagnosing Bell's palsy. 1, 2
• Ordering unnecessary tests—routine labs and imaging are not indicated for typical presentations. 1, 2