What is the immediate treatment for a patient diagnosed with Bell's palsy?

Immediate Treatment for Bell's Palsy

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only evidence-based treatment that significantly improves facial nerve recovery. 1, 2

First-Line Treatment Protocol

Corticosteroid Regimen (Must Start Within 72 Hours)

• Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 2
• Treatment initiated beyond 72 hours has unclear benefit and is not supported by high-quality evidence 3

Combination Therapy Consideration

• May add antiviral therapy to corticosteroids within the 72-hour window as an optional enhancement 1
• Valacyclovir 1 g three times daily for 7 days OR Acyclovir 400 mg five times daily for 10 days 4
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 1
• Never use antiviral monotherapy—it is ineffective and not recommended 1, 2, 4

Immediate Eye Protection (Critical for All Patients)

Implement eye protection immediately for any patient with impaired eye closure to prevent corneal damage. 1, 2

Daytime Protection

• Frequent lubricating ophthalmic drops throughout the day 1, 2
• Sunglasses for outdoor protection against foreign particles 1, 2

Nighttime Protection

• Ophthalmic ointments for more effective 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

Severe Cases Requiring Urgent Ophthalmology Referral

• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Consider botulinum toxin injections, tarsorrhaphy, or eyelid weight implantation for persistent severe lagophthalmos 2

Management Algorithm Based on Presentation Timing

Within 72 Hours of Symptom Onset

1. Start oral corticosteroids immediately 1, 2
2. Consider adding antiviral therapy 1, 4
3. Implement eye protection measures 1, 2
4. No routine laboratory testing or imaging needed for typical presentations 2

Beyond 72 Hours (Day 5 or Later)

1. Do not start corticosteroids—minimal benefit with medication risks 3
2. Focus on comprehensive eye protection 3
3. Counsel patient that 70% with complete paralysis recover spontaneously within 6 months, and up to 94% with incomplete paralysis recover 3, 4
4. Monitor for recovery signs within 2-3 weeks 2

Follow-Up and Referral Criteria

Reassess or refer to a facial nerve specialist if: 1, 2

• New or worsening neurologic findings develop at any point
• Ocular symptoms develop
• Incomplete facial recovery persists 3 months after initial symptom onset
• Atypical features present: bilateral weakness, isolated branch paralysis, other cranial nerve involvement, or recurrence on same side 2

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates the effectiveness of corticosteroid therapy 1, 3
• Using antiviral therapy alone is completely ineffective 1, 2, 4
• Failing to provide adequate eye protection can lead to permanent corneal damage 1, 2
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 2
• Missing atypical features that require imaging to rule out other causes of facial weakness 1, 2

Special Populations

Children

• Higher rates of spontaneous recovery than adults (up to 90%) 4
• Evidence for steroid benefit is less conclusive 1, 2
• Consider treatment on individualized basis with caregiver involvement 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours with careful assessment of benefits and risks 2
• High recovery rates (up to 90%) similar to children 4
• Combination therapy may be considered on individualized basis 2