What is the recommended treatment and dosage for Bell's palsy?

Treatment and Dosage for Bell's Palsy

Prescribe oral prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper, initiated within 72 hours of symptom onset for patients 16 years and older. 1, 2

Primary Treatment Algorithm

Corticosteroid Therapy (MANDATORY)

• Start treatment within 72 hours of symptom onset for maximum benefit 1, 2
• Dosing options:
  • Prednisolone 50 mg orally once daily for 10 days 1, 2, OR
  • Prednisone 60 mg orally once daily for 5 days, then taper over 5 days 1, 2
• Evidence of benefit: 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 2, 3, 4
• At 9 months: 94.4% recovery with prednisolone versus 81.6% with placebo 2, 3, 4
• Number needed to treat: 6 patients to achieve one additional complete recovery 3

Timing Considerations

• Within 24 hours: 66% complete recovery with prednisolone versus 51% without 5
• Within 25-48 hours: 76% complete recovery with prednisolone versus 58% without 5
• Beyond 48 hours: Benefit less clear but still recommended within 72-hour window 1, 5

Antiviral Therapy Decision

DO NOT Use Antivirals Alone

• Antiviral monotherapy is ineffective and should NOT be prescribed 1, 6
• Acyclovir alone showed no benefit: 71.2% recovery versus 75.7% without acyclovir 3, 4

Optional Combination Therapy

• May consider adding antiviral to corticosteroids within 72 hours of onset 1, 2
• Antiviral options if used:
  • Valacyclovir 1 g orally three times daily for 7 days 6, OR
  • Acyclovir 400 mg orally five times daily for 10 days 1, 6
• Evidence is mixed: Some studies show modest improvement (96.5% recovery with combination versus 89.7% with steroids alone), but benefit is small 1
• Consider combination therapy for: Patients with severe complete paralysis or those seeking every possible advantage 1, 6

Essential Eye Protection (MANDATORY)

All patients with impaired eye closure require immediate eye protection to prevent corneal damage 1, 2, 7

Eye Protection Regimen

• Lubricating eye drops: Apply frequently throughout the day 2, 7
• Ophthalmic ointment: Apply at bedtime for overnight protection 2, 7
• Eye patching or taping: Use at night with careful instruction on proper technique 2, 7
• Moisture chambers: Polyethylene covers particularly effective for nighttime 2
• Sunglasses: Wear outdoors for protection against particles and irritants 2, 7

Red Flags Requiring Urgent Ophthalmology Referral

• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Severe lagophthalmos (inability to close eyelid) 2

Special Populations

Children (Under 16 Years)

• Evidence for steroid use is less conclusive in pediatric patients 1, 2
• Children have better prognosis with higher spontaneous recovery rates (up to 90%) 1, 6
• May consider oral steroids on individualized basis with caregiver involvement in decision-making 1

Pregnant Women

• Treat with oral corticosteroids using individualized risk-benefit assessment 2
• Pregnancy (especially third trimester) is a risk factor for Bell's palsy 8
• Recovery rates up to 90% in pregnant women 6

Follow-Up and Referral Triggers

Mandatory Reassessment or Specialist Referral

• Incomplete facial recovery at 3 months after symptom onset 1, 2, 7
• New or worsening neurologic findings at any point 1, 2
• Ocular symptoms developing at any point 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours significantly reduces effectiveness 1, 2, 5
• Using antiviral therapy alone is completely ineffective 1, 6
• Inadequate eye protection can lead to permanent corneal damage 2, 7
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 2
• Failing to refer at 3 months delays access to reconstructive options 2

What NOT to Do

• Do NOT obtain routine laboratory testing for diagnosis 1, 2
• Do NOT routinely perform diagnostic imaging for new-onset Bell's palsy 1, 2
• Do NOT perform electrodiagnostic testing in patients with incomplete facial paralysis 1