What is the best treatment for Bell's palsy?

Best Treatment for Bell's Palsy

Oral corticosteroids prescribed within 72 hours of symptom onset are the definitive first-line treatment for Bell's palsy in patients 16 years and older, with prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Core Treatment Algorithm

Within 72 Hours of Symptom Onset (Treatment Window)

Primary therapy:

• Prednisolone 50 mg daily for 10 days, OR 1
• Prednisone 60 mg daily for 5 days, then 5-day taper 1

The evidence is compelling: 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 1, 2. This represents a 2-fold increase in recovery compared to no steroid treatment 3.

Antiviral therapy considerations:

• Never prescribe antivirals alone—they are ineffective 4, 1
• You may offer combination therapy (antiviral + steroid) within 72 hours, though the benefit is small and not definitively proven 4, 1
• If choosing combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 5
• The decision for combination therapy should involve shared decision-making, as large high-quality trials show no additional benefit, though smaller studies suggest possible modest improvement (96.5% vs 89.7% recovery) 4

Beyond 72 Hours

Do not initiate corticosteroids after 72 hours—there is no evidence of benefit 1, 6. The treatment window has closed.

Essential Eye Protection (All Patients with Impaired Eye Closure)

Implement immediately and continue throughout recovery:

• Lubricating ophthalmic drops frequently throughout the day 1, 6
• Ophthalmic ointments at night (more effective moisture retention despite temporary vision blurring) 1, 6
• Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 1
• Sunglasses for outdoor protection 1
• Consider moisture chambers (polyethylene covers) for nighttime 1

For severe impairment: immediate ophthalmology referral 1

Special Populations

Children

• Better prognosis than adults with up to 90% complete recovery 5
• Evidence for steroid benefit is inconclusive in pediatrics 4, 1
• May consider oral steroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) with substantial caregiver involvement in decision-making 1
• Most children recover completely without treatment 1

Pregnancy

• Treat with oral corticosteroids on an individualized basis within 72 hours 1
• Combination therapy with antivirals may be considered individually 1
• Eye protection remains essential 1

Mandatory Reassessment and Referral Triggers

Refer to facial nerve specialist if:

• Incomplete facial recovery at 3 months after symptom onset 1, 6
• New or worsening neurologic findings at any point 1, 6
• Ocular symptoms developing at any point 1, 6

MRI with and without contrast indicated for:

• Atypical presentations (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) 1
• No recovery after 3 months 1
• Second paralysis on same side 1

What NOT to Do (Critical Pitfalls)

• Never prescribe antiviral monotherapy—it is completely ineffective 4, 1, 2
• Never initiate steroids beyond 72 hours—no evidence of benefit 1, 6
• Never restart or extend corticosteroids beyond the initial 10-day course 6
• Never order routine laboratory testing or imaging for typical Bell's palsy 1
• Never neglect eye protection even if patient's primary complaint is pain 6

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks 1, 6
• Complete recovery typically occurs within 3-4 months 1, 6
• 70% with complete paralysis recover fully within 6 months 1
• 94% with incomplete paralysis recover fully 1
• 30% may experience permanent facial weakness with muscle contractures 1

Additional Supportive Measures

Physical therapy:

• May be beneficial for patients with more severe paralysis and developing synkinesis 7, 5
• Evidence for specific protocols is limited 1, 6

Pain management (if persistent beyond 2 weeks):

• Consider gabapentin 1800-3600 mg/day divided three times daily for neuropathic pain 6