What is the treatment for Bell's palsy?

Treatment for Bell's Palsy

Immediate Treatment: Oral Corticosteroids Within 72 Hours

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

Recommended Corticosteroid Regimens

• Prednisolone 50 mg once daily for 10 days (preferred regimen) 1, 2
• Alternative: Prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1, 2
• Administer as a single daily dose, not divided doses 3
• Maximum dose should not exceed 60 mg daily 3

Evidence Supporting Early Steroid Use

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1, 2
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 2, 3
• The 72-hour window exists because early treatment reduces facial nerve inflammation before permanent damage occurs 1, 3
• Clinical trials demonstrating benefit specifically enrolled patients within 72 hours—no high-quality evidence supports treatment after this window 1

Critical Pitfall: Do NOT Start Steroids After 72 Hours

Starting corticosteroids beyond 72 hours provides minimal benefit and exposes patients to medication risks without proven efficacy. 1, 3

• If a patient presents on day 5 or later, focus on supportive care and eye protection rather than initiating steroids 1
• Avoid methylprednisolone dose packs—they provide only 84 mg total over 6 days, which is grossly inadequate compared to the recommended 540 mg prednisone over 14 days 3

Antiviral Therapy: Optional Add-On, Never Alone

When to Consider Antivirals

• May offer combination therapy (oral antiviral + corticosteroid) within 72 hours of symptom onset 2
• Some evidence shows higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%) 2
• Recommended antivirals: Valacyclovir 1 g three times daily for 7 days OR Acyclovir 400 mg five times daily for 10 days 4

Critical Warning About Antivirals

Never prescribe antiviral monotherapy—it is completely ineffective and not recommended. 1, 2, 4

• Antivirals alone show no benefit compared to placebo 1, 2
• The benefit of adding antivirals to steroids is small but risks are minimal 2

Essential Eye Protection for All Patients

Implement aggressive eye protection immediately for any patient with impaired eye closure to prevent corneal damage—this is mandatory regardless of treatment timing. 1, 2

Daytime Protection

• Lubricating ophthalmic drops frequently throughout the day 1, 2
• Sunglasses for outdoor protection against foreign particles and irritants 1, 2

Nighttime Protection

• Ophthalmic ointments for more effective moisture retention (may cause 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 particularly effective at night 2

When to Refer to Ophthalmology

• Immediate referral for severe impairment or persistent lagophthalmos 1, 3
• Eye pain, vision changes, redness, discharge, or foreign body sensation despite protection measures 2
• Consider botulinum toxin injections, tarsorrhaphy (partial eyelid closure), or eyelid weight implantation for persistent severe cases 2

Special Populations

Children

• Children have better prognosis with higher rates of spontaneous recovery (up to 90%) than adults 2, 4
• Evidence for steroid benefit in children is inconclusive—no high-quality pediatric-specific trials exist 2
• Consider oral steroids on an individualized basis with substantial caregiver participation in decision-making 2
• Dosing if treating: Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, followed by a 5-day taper 2

Pregnant Women

• Treat pregnant women with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults 1, 2
• Pregnant women have up to 90% complete recovery rates 4
• Treatment should be individualized with careful assessment of benefits and risks 1, 2

Follow-Up and Referral Criteria

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks of symptom onset 1, 2, 3
• Complete recovery typically occurs within 3-4 months 2, 3
• 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

Mandatory Reassessment or Specialist Referral

Refer to a facial nerve specialist or facial plastic surgeon if: 1, 2

• Incomplete facial recovery persists 3 months after initial symptom onset 1, 2, 3
• New or worsening neurologic findings develop at any point 1, 2
• Ocular symptoms develop at any point 1, 2

Imaging Indications

• MRI with and without contrast is the imaging test of choice when indicated 2
• Order imaging for: atypical presentations, no recovery after 3 months, second paralysis on same side, isolated branch paralysis, or other cranial nerve involvement 2
• Routine laboratory testing and diagnostic imaging are NOT recommended for initial Bell's palsy diagnosis 2

What NOT to Do

• Do not prescribe antiviral monotherapy—it is ineffective 1, 2, 4
• Do not start steroids beyond 72 hours—no proven benefit 1, 3
• Do not use methylprednisolone dose packs—inadequate dosing 3
• Do not fail to provide eye protection—can lead to permanent corneal damage 1, 2
• Do not delay specialist referral at 3 months—delays access to reconstructive options 2

Prognosis and Long-Term Outcomes

• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 2, 3
• Patients with persistent paralysis experience significant psychosocial dysfunction requiring active management 2
• Reconstructive surgery options (eyelid weights, brow lifts, facial slings, nerve transfers) available for incomplete recovery beyond 3 months 2