What is the immediate treatment for a patient 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 treatment proven to significantly improve facial nerve recovery. 1, 2, 3

First-Line Treatment Protocol

Prescribe one of these corticosteroid regimens within 72 hours:

• Prednisolone 50 mg daily for 10 days, OR 2, 3
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 2, 3

The evidence strongly supports this approach: 83% of patients recover at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recover at 9 months versus 81.6% with placebo. 3

Critical Timing Considerations

The 72-hour window is non-negotiable for steroid efficacy. 1, 2

• All clinical trials demonstrating steroid benefit specifically enrolled patients within 72 hours of symptom onset 1
• Starting steroids after 72 hours provides minimal benefit and exposes patients to medication risks without clear evidence of effectiveness 1
• If a patient presents on day 5 or later, do not start steroids—focus entirely on eye protection instead 1

Antiviral Therapy Decision

Consider adding antiviral therapy to steroids (not alone) within 72 hours, particularly for severe cases: 2, 3

• Valacyclovir 1 g three times daily for 7 days, OR 4
• Acyclovir 400 mg five times daily for 10 days 4

One study showed 96.5% complete recovery with combination therapy versus 89.7% with steroids alone, though the benefit is small. 2 However, never prescribe antivirals as monotherapy—they are completely ineffective alone. 2, 3

The evidence is somewhat mixed on combination therapy. While some studies show benefit 5, the most recent guidelines note the advantage is modest. 2 Given minimal risks, combination therapy is reasonable for severe paralysis when initiated within 72 hours. 6

Immediate Eye Protection (Critical for All Patients)

Implement comprehensive eye protection immediately for any patient with impaired eye closure—this prevents potentially permanent corneal damage: 1, 2, 3

Daytime Protection:

• Lubricating ophthalmic drops applied frequently throughout the day 1, 3
• Sunglasses for outdoor protection against foreign particles 1, 3

Nighttime Protection (Most Critical):

• Ophthalmic ointments for superior moisture retention 1, 3
• Eye patching or taping (with careful instruction on proper technique to avoid corneal abrasion) 1, 3
• Moisture chambers using polyethylene covers 3

Severe Cases Requiring Urgent Ophthalmology Referral:

• Complete inability to close the eye 3
• Eye pain, vision changes, redness, or discharge 3
• Sensation of foreign body despite protection measures 3

Patient Age Considerations

For patients 16 years and older: Follow the standard corticosteroid protocol above. 2, 3

For children: The evidence for steroid benefit is less conclusive since children have higher spontaneous recovery rates (up to 90%). 3, 4 Consider steroids on an individualized basis with caregiver involvement, but recognize that natural recovery is more likely than in adults. 3

For pregnant women: Treat with oral corticosteroids within 72 hours using individualized assessment of benefits versus risks. 3 The treatment approach should be the same as non-pregnant patients given the significant morbidity of incomplete recovery. 3

What NOT to Do (Common Pitfalls)

• Do not order routine laboratory tests or imaging for typical Bell's palsy presentations 2, 3
• Do not prescribe antivirals alone—they are ineffective as monotherapy 2, 3, 4
• Do not start steroids after 72 hours—this exposes patients to medication risks without proven benefit 1
• Do not fail to provide eye protection—corneal damage can be permanent 1, 2, 3
• Do not forget to rule out other causes of facial weakness through careful history and physical examination before diagnosing Bell's palsy 2

Follow-Up Requirements

Schedule reassessment or refer to a facial nerve specialist if: 2, 3

• New or worsening neurologic findings develop at any point 2, 3
• Ocular symptoms develop at any point 2, 3
• Incomplete facial recovery persists 3 months after initial symptom onset 2, 3

Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 3 Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment, while those with incomplete paralysis have recovery rates up to 94%. 1, 3