Treatment for Bell's Palsy
Immediate Treatment: Oral Corticosteroids Within 72 Hours
Prescribe oral corticosteroids within 72 hours of symptom onset for all Bell's palsy patients aged 16 years and older—this is the only treatment proven to significantly improve facial nerve recovery. 1
Recommended Corticosteroid Regimens
- Prednisolone 50 mg once daily for 10 days (preferred regimen) 1
- Alternative: Prednisone 60 mg once daily for 5 days, followed by a 5-day taper (reducing by 10 mg daily) 1, 2
- Administer as a single daily dose, not divided doses 3
Evidence Supporting Corticosteroids
The evidence for corticosteroids is robust and compelling: 1
- 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1
- 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1
- Patients with incomplete paralysis achieve up to 94% recovery rates 1
Critical Timing Window
Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence supporting benefit after this window, and you only expose patients to medication risks without proven efficacy. 4, 3 The 72-hour window exists because early treatment reduces facial nerve inflammation before permanent damage occurs. 4, 3
Antiviral Therapy Considerations
Combination Therapy Option
You may offer oral antiviral therapy in addition to oral corticosteroids within 72 hours of symptom onset, particularly for patients with severe or complete paralysis. 1 While the benefit is small, the risks are minimal. 1
Recommended antiviral regimens: 2
Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), and combination therapy may reduce rates of synkinesis (involuntary co-contraction of facial muscles from misdirected nerve fiber regrowth). 1, 2
Critical Pitfall
Never prescribe antiviral monotherapy—it is completely ineffective and not recommended. 1, 4, 2 Antivirals only have potential benefit when combined with corticosteroids. 1
Essential Eye Protection for All Patients
Implement aggressive eye protection immediately for any patient with impaired eye closure to prevent corneal damage—this is a strong recommendation based on the preponderance of benefit over harm. 1, 4
Eye Protection Algorithm by Severity
For all patients with lagophthalmos: 1
- Lubricating ophthalmic drops frequently throughout the day (does not blur vision but requires repeated application) 1
- Ophthalmic ointments at night for more effective moisture retention (may cause temporary vision blurring) 1
- Moisture chambers using polyethylene covers for nighttime protection 1
- Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 1
- Sunglasses for outdoor protection against foreign particles 1
For severe impairment: 1
- Immediate ophthalmology referral for evaluation 1
- Consider botulinum toxin injections for temporary improvement lasting months 1
- Consider tarsorrhaphy (temporary or permanent partial eyelid closure) 1
- Consider eyelid weight implantation 1
Warning Signs Requiring Urgent Ophthalmology Referral
Patients must seek immediate medical attention for: 1
- Eye pain or changes in vision 1
- Redness, discharge, or sensation of foreign body 1
- Increasing irritation despite protection measures 1
Special Populations
Children
Children have a better prognosis than adults with higher rates of spontaneous recovery (up to 90%). 1, 2 However, the benefit of corticosteroid treatment in children is inconclusive due to lack of high-quality pediatric-specific trials. 1
For pediatric patients: 1
- Consider oral corticosteroids for severe or complete paralysis cases with substantial caregiver participation in shared decision-making 1
- If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper 1
- Inform families that most children recover completely without treatment 1
Pregnant Women
Treat pregnant women with oral corticosteroids within 72 hours of symptom onset with careful assessment of benefits and risks. 1 Combination therapy with oral antivirals and corticosteroids may be considered on an individualized basis. 1
Diagnostic Testing: What NOT to Do
Do not order routine laboratory testing or diagnostic imaging for initial Bell's palsy diagnosis. 1 The diagnosis is clinical, based on acute unilateral facial weakness involving the forehead with onset in less than 72 hours without identifiable cause. 1
When Imaging IS Indicated
Order MRI with and without contrast for: 1
- Atypical presentations (second paralysis on same side, isolated branch paralysis, other cranial nerve involvement) 1
- No sign of recovery after 3 months 1
- New or worsening neurologic findings at any point 1
Follow-Up and Referral Triggers
Mandatory Reassessment or Specialist Referral
Refer patients to a facial nerve specialist at 3 months if incomplete facial recovery persists. 1, 4 Also refer immediately for: 1
- New or worsening neurologic findings at any point 1
- Ocular symptoms developing at any point 1
- Persistent incomplete eye closure requiring ophthalmology evaluation 1
Expected Recovery Timeline
Most patients begin showing signs of recovery within 2-3 weeks of symptom onset, with complete recovery typically occurring within 3-4 months. 1, 4 Approximately 70% of patients with complete paralysis recover facial function completely within 6 months, while patients with incomplete paralysis have recovery rates up to 94%. 1, 4
However, approximately 30% may experience permanent facial weakness with muscle contractures, requiring long-term management including potential reconstructive surgery and psychological support. 1
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours reduces effectiveness and provides minimal benefit 1, 4, 3
- Using methylprednisolone dose packs which provide only 84 mg total over 6 days—grossly inadequate compared to 540 mg prednisone over 14 days 3
- Prescribing antiviral monotherapy which is completely ineffective 1, 4, 2
- Inadequate eye protection leading to permanent corneal damage 1, 4
- Failing to refer at 3 months for incomplete recovery, delaying access to reconstructive options 1, 4
- Improper eye taping technique causing corneal abrasion—patients must be carefully instructed 1