Treatment for Bell's Palsy
Immediate Treatment: Corticosteroids Within 72 Hours
Prescribe oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—this is the only treatment proven to significantly improve facial nerve recovery. 1, 2
Recommended Corticosteroid Regimens
- Prednisolone 50 mg daily for 10 days (preferred option) 1, 2
- OR Prednisone 60 mg daily for 5 days, followed by a 5-day taper 1, 2
Evidence Supporting Early Corticosteroid Use
- Treatment within 72 hours achieves 83% complete recovery at 3 months versus 63.6% with placebo 2, 3
- At 9 months, recovery rates reach 94.4% with prednisolone versus 81.6% without treatment 2, 3
- The number needed to treat is only 6 patients to achieve one additional complete recovery 3
Critical Pitfall: Starting corticosteroids after 72 hours provides minimal benefit and exposes patients to medication risks without clear evidence of efficacy—the therapeutic window is firmly established at 72 hours. 1
Antiviral Therapy Considerations
When to Add Antivirals
Consider adding oral antiviral therapy to corticosteroids (not as monotherapy) within the 72-hour window, though the benefit is small. 2, 4
- Valacyclovir 1 g three times daily for 7 days 4, 5
- OR Acyclovir 400 mg five times daily for 10 days 4
Evidence for Combination Therapy
- Some studies show combination therapy achieves 96.5% complete recovery versus 89.7% with steroids alone 2
- However, the largest high-quality trial (BELLS study) found no significant benefit of adding aciclovir to prednisolone 3
- The American Academy of Otolaryngology-Head and Neck Surgery states antivirals may be offered as an option but are not strongly recommended 2
Critical Pitfall: Never prescribe antiviral therapy alone—it is completely ineffective without corticosteroids. 1, 2, 4
Eye Protection: Essential for All Patients with Impaired Eye Closure
Implement aggressive eye protection immediately for any patient who cannot fully close their affected eye—corneal damage is preventable but can be permanent if neglected. 1, 2
Daytime Protection
- Lubricating ophthalmic drops frequently throughout the day (does not blur vision but requires repeated application) 1, 2
- Sunglasses for outdoor protection against foreign particles and irritants 1, 2
Nighttime Protection
- Ophthalmic ointments at bedtime (more effective moisture retention, though causes temporary vision blurring) 1, 2
- Eye patching or taping with careful instruction on proper technique to avoid corneal abrasion 1, 2
- Moisture chambers using polyethylene covers for severe cases 2
When to Refer to Ophthalmology
- Severe impairment of eye closure at presentation 2
- Development of eye pain, vision changes, redness, discharge, or foreign body sensation 2
- Persistent lagophthalmos beyond 3 months 2
Critical Pitfall: Relying solely on daytime drops without nighttime protection leads to exposure keratitis—patients need both. 2
Follow-Up and Referral Criteria
Mandatory Reassessment or Specialist Referral
Refer to a facial nerve specialist if any of the following occur: 1, 2
- Incomplete facial recovery at 3 months after symptom onset 1, 2
- New or worsening neurologic findings at any point 1, 2
- Development of ocular symptoms at any point 1, 2
Expected Recovery Timeline
- Most patients begin showing recovery within 2-3 weeks of symptom onset 1, 2
- Complete recovery typically occurs within 3-4 months 2
- Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment 1, 2
- Patients with incomplete paralysis have higher recovery rates up to 94% 1, 2
Special Populations
Children
- Children have better prognosis with higher spontaneous recovery rates than adults 1, 2
- Evidence for corticosteroid benefit in children is less conclusive 2
- Consider treatment on an individualized basis with caregiver involvement 2
Pregnant Women
- Treat with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults 2
- Pregnant women should receive individualized assessment of benefits and risks 1, 2
- Recovery rates in pregnancy approach 90% 4
What NOT to Do
Do not order routine laboratory testing or imaging for typical Bell's palsy presentations—diagnosis is clinical. 2
Do not prescribe physical therapy or acupuncture as primary treatment—evidence is insufficient to support these interventions, though physical therapy may help patients with severe paralysis and developing synkinesis. 2, 6
Do not delay treatment waiting for test results—every hour counts within the 72-hour window. 1, 2