What is the recommended treatment for Bell's (Bell's) palsy?

Bell's Palsy Emergency Department Treatment

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—and implement aggressive eye protection measures for all patients with impaired eye closure. 1, 2

Treatment Algorithm Based on Time of Presentation

Within 72 Hours of Symptom Onset (Treatment Window)

Corticosteroid Therapy (First-Line)

• Prescribe prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with 5-day taper 1, 2
• This regimen achieves 83% complete recovery at 3 months versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 2, 3
• The benefit is only established when treatment begins within this 72-hour window—clinical trials demonstrating efficacy specifically enrolled patients within this timeframe 1

Antiviral Therapy Considerations

• Do NOT prescribe antivirals alone—they are completely ineffective as monotherapy 1, 2
• May offer combination therapy (oral corticosteroid PLUS antiviral) within 72 hours as an option, though the additional benefit is small 2
• If choosing combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 4
• The landmark 2007 trial showed no benefit from acyclovir alone (71.2% recovery) versus no acyclovir (75.7% recovery) 3

Beyond 72 Hours of Symptom Onset

Do NOT initiate corticosteroids after 72 hours—there is no evidence supporting benefit after this window, and you expose patients to medication risks without proven efficacy 1

Focus entirely on supportive care and eye protection at this stage 1

Mandatory Eye Protection Protocol (All Patients with Lagophthalmos)

Implement immediately regardless of timing:

• Daytime protection: Lubricating ophthalmic drops every 1-2 hours while awake 2
• Nighttime protection: Ophthalmic ointment at bedtime for sustained moisture retention 2
• Mechanical protection: Eye taping or patching at night (with careful instruction on proper technique to avoid corneal abrasion) 1, 2
• Outdoor protection: Sunglasses to shield against wind and foreign particles 2
• Severe cases: Consider moisture chambers using polyethylene covers 1, 2

Urgent ophthalmology referral if:

• Complete inability to close the eye 2
• Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1

Diagnostic Workup in the ED

Do NOT order routine laboratory tests or imaging for typical Bell's palsy 2

Red flags requiring imaging (MRI with and without contrast):

• Bilateral facial weakness 2
• Isolated branch paralysis (not affecting entire side of face) 2
• Other cranial nerve involvement 2
• Gradual onset over weeks rather than acute onset within 72 hours 2
• History of trauma, known malignancy, or immunocompromise 2

Special Populations

Children:

• Have better prognosis with up to 90-94% spontaneous recovery rates 2, 4
• Evidence for corticosteroid benefit is less conclusive than in adults 2
• May consider oral steroids for severe/complete paralysis with caregiver involvement in shared decision-making 2
• Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treating 2

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 2
• Short-term corticosteroid use is generally considered acceptable 2
• Eye protection is especially critical 2

ED Discharge Instructions and Follow-Up

Patient education on natural history:

• Most patients begin showing recovery within 2-3 weeks 1, 2
• 70% with complete paralysis recover fully within 6 months even without treatment 1
• 94% with incomplete paralysis recover fully 1

Mandatory follow-up/referral triggers:

• Incomplete facial recovery at 3 months after onset 1, 2
• New or worsening neurologic findings at any point 1, 2
• Development of ocular symptoms (pain, vision changes, redness) 1, 2

Critical Pitfalls to Avoid

• Starting steroids beyond 72 hours—provides minimal benefit and exposes patients to unnecessary medication risks 1
• Prescribing antiviral monotherapy—completely ineffective and should never be done 1, 2
• Inadequate eye protection counseling—can lead to permanent corneal damage in patients with lagophthalmos 1, 2
• Ordering unnecessary imaging for typical presentations—wastes resources and delays treatment 2
• Failing to assess forehead involvement—critical for distinguishing Bell's palsy (forehead affected) from central causes like stroke (forehead spared) 2