What is the treatment for Bell's Palsy?

Treatment of Bell's Palsy

Prescribe oral corticosteroids (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper) within 72 hours of symptom onset for all patients 16 years and older, combined with aggressive eye protection measures for those with impaired eye closure. 1

Immediate Treatment Algorithm (Within 72 Hours)

Primary Pharmacologic Therapy

• Initiate oral corticosteroids immediately if the patient presents within 72 hours of symptom onset 1
• Use prednisolone 50 mg daily for 10 days as the preferred regimen 1
• Alternative: prednisone 60 mg daily for 5 days, then taper by 10 mg daily over the next 5 days 1, 2
• Strong evidence supports this approach: 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% without treatment 1, 3

Antiviral Therapy Considerations

• Do NOT prescribe antiviral monotherapy - it is ineffective and not recommended 1, 2, 3
• May offer combination therapy (oral corticosteroids PLUS antivirals) within 72 hours as an option, though benefit is small 1
• If choosing combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 2, 4
• Some evidence shows combination therapy achieves 96.5% complete recovery versus 89.7% with steroids alone, but this marginal benefit must be weighed against minimal additional risk 1

Essential Eye Protection Protocol

For All Patients with Impaired Eye Closure

• Implement immediately to prevent corneal damage, which is a strong recommendation based on expert opinion 1
• Daytime protection: Frequent lubricating ophthalmic drops (does not blur vision but requires repeated application) 1
• Nighttime protection: Ophthalmic ointments for superior moisture retention (causes temporary vision blurring) 1
• Mechanical protection: Eye patching or taping at night with careful instruction on proper technique to avoid corneal abrasion 1
• Outdoor protection: Sunglasses to shield against foreign particles and irritants 1
• Severe cases: Consider moisture chambers using polyethylene covers, particularly for nighttime 1

Urgent Ophthalmology Referral Indicators

• Eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection measures 1
• Severe impairment with significant lagophthalmos requires immediate ophthalmology evaluation 1

Treatment Beyond 72 Hours

If the patient presents after 72 hours (e.g., Day 5), do NOT initiate corticosteroids - the evidence supports efficacy only within the 72-hour window, and later administration exposes patients to medication risks without proven benefit 5

Management for Late Presenters

• Focus exclusively on eye protection using the protocol above 5
• Reassure that approximately 70% of patients with complete paralysis recover fully within 6 months even without corticosteroid treatment 5, 6
• Patients with incomplete paralysis have even higher recovery rates up to 94% 5
• Monitor for signs of recovery, which typically begin within 2-3 weeks 5

Special Population Considerations

Children

• Better prognosis than adults with higher spontaneous recovery rates 1
• Evidence for corticosteroid benefit in children is inconclusive 1
• Decision should involve substantial caregiver participation in shared decision-making 1
• If treating: prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper, only within 72 hours 1
• Most children recover completely without treatment 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Pregnant women have up to 90% complete recovery rates 2
• Combination therapy with antivirals may be considered on an individualized basis 1
• Eye protection remains essential 1

Follow-Up and Referral Triggers

Mandatory Reassessment or Specialist Referral

• Incomplete facial recovery at 3 months after initial symptom onset 1, 5
• New or worsening neurologic findings at any point 1, 5
• Development of ocular symptoms at any point 1, 5

Imaging Indications

• MRI with and without contrast is the test of choice for: atypical presentations, no recovery after 3 months, second paralysis on same side, isolated branch paralysis, or other cranial nerve involvement 1

Long-Term Management (Beyond 3 Months)

For Persistent Incomplete Recovery

• Refer to facial nerve specialist or facial plastic surgeon for evaluation of reconstructive procedures 1
• Ophthalmology referral for persistent eye closure problems 1
• Surgical options include: tarsorrhaphy (temporary or permanent partial eyelid closure), eyelid weight implantation, static procedures (brow lifts, facial slings), or dynamic procedures (nerve transfers) 1

Psychological Support

• Patients with persistent facial paralysis experience significant psychosocial dysfunction, difficulty expressing emotion, stigmatization, and elevated depression risk 1
• Active management and specialist referral for psychological support is essential 1

Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces or eliminates corticosteroid effectiveness 1, 5
• Using antiviral monotherapy is completely ineffective and should never be prescribed 1, 2, 3
• Inadequate eye protection can lead to permanent corneal damage in patients with lagophthalmos 1, 5
• Improper eye taping technique can cause corneal abrasion - patients must receive careful instruction 1
• Failing to refer at 3 months delays access to reconstructive options and psychological support 1
• Routine laboratory testing and imaging are NOT recommended for initial diagnosis 1

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks of symptom onset 1, 5
• Complete recovery typically occurs within 3-4 months for most patients 1
• Approximately 30% may experience permanent facial weakness with muscle contractures 1, 6
• With early corticosteroid treatment: 83% recover at 3 months and 94.4% at 9 months 1, 3