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

Initial Treatment for Bell's Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy. 1, 2

Corticosteroid Regimen

The evidence-based dosing is:

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

Evidence Supporting Corticosteroids

The landmark trial data demonstrates compelling efficacy:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 2, 4
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 2, 4
• Number needed to treat is only 6 patients at 3 months to achieve one additional complete recovery 5

The treatment window is critical—efficacy diminishes rapidly after 72 hours from symptom onset. 1, 2, 3

Antiviral Therapy Considerations

Do NOT prescribe antiviral therapy alone—it is ineffective. 1, 2, 3

However, you may offer combination therapy (oral antiviral + corticosteroid) within 72 hours as an optional add-on:

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

The evidence here is mixed. While the highest quality trial showed no benefit from acyclovir either alone or in combination with prednisolone 4, 5, some data suggests combination therapy may reduce synkinesis rates (involuntary facial muscle co-contraction from misdirected nerve regrowth). 3 The American Academy of Otolaryngology-Head and Neck Surgery classifies this as an option rather than a recommendation, acknowledging the benefit is small but risks are minimal. 1, 2

Mandatory Eye Protection

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

Specific Eye Protection Measures:

• Lubricating ophthalmic drops frequently throughout the day 2
• Ophthalmic ointments at bedtime for sustained moisture retention 2
• Eye patching or taping at night (with careful instruction on proper technique to avoid corneal abrasion) 2
• Sunglasses for outdoor protection against particles and irritants 2
• Moisture chambers using polyethylene covers for nighttime protection 2

For severe impairment with complete inability to close the eye, refer immediately to ophthalmology. 2

Diagnostic Approach Before Treatment

Before initiating treatment, perform a focused assessment to exclude alternative diagnoses:

Key History and Physical Examination Elements:

• Confirm unilateral facial weakness involving the forehead (distinguishes from stroke, which spares forehead) 2, 6
• Verify rapid onset within 72 hours 2, 6
• Assess severity using House-Brackmann grading scale (Grade 1 = normal to Grade 6 = complete paralysis) 2, 6
• Evaluate all facial movements: raising eyebrows, closing eyes tightly, smiling, puffing cheeks 6
• Check for red flags suggesting alternative diagnosis 6:
  • Bilateral facial weakness
  • Other cranial nerve involvement
  • Isolated branch paralysis
  • History of head/neck cancer
  • Slow progression beyond 72 hours

Testing NOT Recommended:

• Do NOT obtain routine laboratory testing 1, 2
• Do NOT perform routine diagnostic imaging 1, 2
• Do NOT perform electrodiagnostic testing for incomplete paralysis 1, 2

These tests add no value for typical Bell's palsy presentations and delay treatment. 1, 2

Special Populations

Pregnant Women:

• Treat with oral corticosteroids on an individualized basis after discussing benefits and risks 2
• Pregnant women have excellent prognosis with up to 90% complete recovery 3

Children:

• Children have better prognosis than adults with higher spontaneous recovery rates 2
• Evidence for corticosteroid benefit in children is less conclusive, but may be offered on individualized basis 2

Patients with Diabetes:

• Higher risk for Bell's palsy but should still receive corticosteroids 6
• Monitor glucose closely during treatment 6

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours—this is the most critical error as efficacy drops significantly 2, 3
• Using antiviral monotherapy—completely ineffective 1, 2, 3
• Inadequate eye protection counseling—can lead to permanent corneal damage 2
• Failing to assess forehead involvement—missing this leads to misdiagnosis of stroke as Bell's palsy 6
• Ordering unnecessary tests—delays treatment and provides no diagnostic value 1, 2

Follow-Up Requirements

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

• New or worsening neurologic findings at any point
• Ocular symptoms develop at any point
• Incomplete facial recovery at 3 months after onset

Most patients begin recovery within 2-3 weeks, with complete recovery typically by 3-4 months. 2 Approximately 70% with complete paralysis and 94% with incomplete paralysis achieve full recovery. 2, 6