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

Immediate Treatment for Bell's Palsy

Start oral corticosteroids immediately within 72 hours of symptom onset—this is the single most important intervention that significantly improves facial nerve recovery. 1

First-Line Treatment Protocol

Prescribe one of these corticosteroid regimens: 1, 2

• Prednisolone 50 mg daily for 10 days, OR
• Prednisone 60 mg daily for 5 days, then taper by 10 mg daily over the next 5 days 1, 3

The evidence is compelling: 83% of patients recover at 3 months with prednisolone versus only 63.6% with placebo, and 94.4% recover at 9 months versus 81.6% with placebo. 2 Do not delay—treatment effectiveness drops significantly after the 72-hour window. 1

Combination Therapy Consideration

Consider adding antiviral therapy to corticosteroids for potentially better outcomes: 1

• Valacyclovir 1 g three times daily for 7 days, OR 3
• Acyclovir 400 mg five times daily for 10 days 3

While the American Academy of Otolaryngology-Head and Neck Surgery states combination therapy "may be considered as an option," the research evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%). 1 One study demonstrated 87.5% complete recovery with valacyclovir plus prednisone versus 68% with no treatment, with particularly pronounced benefits in elderly patients (100% recovery in treated patients over 60 versus 42% in untreated). 4

Critical caveat: Never use antiviral monotherapy—it is ineffective and explicitly not recommended. 1, 3

Immediate Eye Protection

Implement eye protection measures immediately for any patient with impaired eye closure: 1, 2

• Lubricating ophthalmic drops frequently throughout the day 2
• Ophthalmic ointment at bedtime (more effective moisture retention but causes temporary vision blurring) 2
• Eye patching or taping at night (requires careful instruction on proper technique to avoid corneal abrasion) 2
• Sunglasses for outdoor protection 2
• Moisture chambers using polyethylene covers for nighttime 2

Failure to provide adequate eye protection can lead to corneal damage and is a common pitfall. 1

Age-Specific Considerations

For patients 16 years and older: Use the full corticosteroid regimen as outlined above. 1, 2

For children: Evidence for steroid benefit is less conclusive as children show higher spontaneous recovery rates (up to 90%). 2, 3 Consider oral steroids on an individualized basis with caregiver involvement. 2

For pregnant women: Treat with oral corticosteroids on an individualized basis with careful assessment of benefits versus risks. 2 Combination therapy with antivirals may also be considered individually. 2

What NOT to Do

Avoid these critical errors: 1, 2

• Do not delay treatment beyond 72 hours—effectiveness drops significantly 1
• Do not prescribe antiviral monotherapy—it is ineffective 1, 3
• Do not order routine laboratory testing or imaging for typical presentations 1, 2
• Do not fail to provide eye protection for patients with impaired eye closure 1
• Do not diagnose Bell's palsy without ruling out other causes of facial weakness through thorough history and physical examination 1

When to Reassess or Refer

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

Algorithm Summary

1. Confirm diagnosis through history and physical examination (acute unilateral facial weakness involving forehead, onset <72 hours, no other identifiable cause) 2
2. Start corticosteroids immediately if within 72-hour window 1, 2
3. Add antiviral therapy for potentially better outcomes, especially in severe cases 1, 3, 4
4. Implement eye protection immediately if impaired eye closure present 1, 2
5. Schedule follow-up at 3 months to assess recovery 1, 2