What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Primary Treatment: Oral Corticosteroids

Prescribe oral corticosteroids within 72 hours of symptom onset for all Bell's palsy patients 16 years and older—this is the single most important intervention that significantly improves facial nerve recovery. 1

Recommended Corticosteroid Regimens

Choose one of the following evidence-based regimens:

• Prednisolone 50 mg once daily for 10 days 1
• Prednisone 60 mg once daily for 5 days, followed by a 5-day taper 1

The evidence supporting this recommendation is robust: 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

Critical Timing Considerations

• Treatment must be initiated within 72 hours of symptom onset—beyond this window, there is no evidence of benefit. 1, 2
• Administer as a single daily dose, not divided doses, to optimize therapeutic effect. 2
• Do not restart or extend corticosteroid therapy beyond the initial course—only the initial treatment window is evidence-based. 3

Eye Protection: Essential Concurrent Management

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage. 1

Structured Eye Protection Protocol

During waking hours:

• Apply lubricating ophthalmic drops every 1-2 hours while awake [1, @12@]
• Use sunglasses outdoors for protection against wind and foreign particles [1, @12@]

At bedtime:

• Apply ophthalmic ointment for sustained moisture retention [1, @12@]
• Consider eye taping or patching with careful instruction on proper technique to avoid corneal abrasion [1, @12@]
• Use moisture chambers with polyethylene covers for severe cases [1, @12@]

Urgent ophthalmology referral required for:

• Severe impairment with complete inability to close the eye [@12@]
• Any signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1

Antiviral Therapy: Limited Role

Do not prescribe antiviral therapy alone—it is ineffective as monotherapy. 1, 4

You may offer combination therapy (oral antiviral plus corticosteroids) within 72 hours of symptom onset as an option, though the benefit is small. 1 If choosing combination therapy:

• Valacyclovir 1 gram three times daily for 7 days, OR 4
• Acyclovir 400 mg five times daily for 10 days 4

Some evidence shows marginally higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), but the incremental benefit is minimal. 1

Special Populations

Children

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) than adults. 1, 4
• The benefit of corticosteroid treatment in children is inconclusive—no high-quality pediatric-specific trials exist. [1, @11@]
• Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis cases with substantial caregiver involvement in shared decision-making. [@11@]

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized assessment of benefits and risks. 1
• Combination therapy with antivirals may be considered on an individualized basis. 1

Diagnostic Testing: What NOT to Do

Do not order routine laboratory testing or diagnostic imaging for typical Bell's palsy presentation. 1

When Imaging IS Indicated

Order MRI with and without contrast for:

• Atypical presentations (second paralysis on same side, isolated branch paralysis, other cranial nerve involvement) [1, @12@]
• No sign of recovery after 3 months [1, @12@]
• New or worsening neurologic findings at any point [1, @12@]

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral Required For:

• Incomplete facial recovery at 3 months after symptom onset [1, @12@]
• New or worsening neurologic findings at any point [1, @12@]
• Development of ocular symptoms at any point [1, @12@]

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks of symptom onset. 1
• Complete recovery typically occurs within 3-4 months. 1
• Approximately 70% of patients with complete paralysis recover fully within 6 months; those with incomplete paralysis have recovery rates up to 94%. 1
• Approximately 30% may experience permanent facial weakness with muscle contractures. 1

Therapies NOT Recommended

Do not offer the following interventions:

• Acupuncture—no recommendation can be made due to poor-quality trials and indeterminate benefit-harm ratio. 1
• Physical therapy as primary treatment—limited evidence (only case series) with equilibrium of benefit and harm, though it may be beneficial for patients with severe paralysis developing synkinesis. 1, 3
• Surgical decompression—rarely indicated except in specialized centers comparing it with medical management. [@12@]

Common Pitfalls to Avoid

• Avoid methylprednisolone dose packs—they provide only 84 mg total over 6 days, grossly inadequate compared to the recommended 540 mg prednisone over 14 days. 2
• Do not delay treatment beyond 72 hours—effectiveness diminishes significantly after this window. 1, 2
• Do not fail to test forehead function—this is critical to distinguish Bell's palsy from central causes of facial weakness. 1
• Do not neglect eye protection even if the patient's primary complaint is pain rather than eye symptoms—corneal damage can occur silently. 3
• Do not fail to refer at 3 months if recovery is incomplete—this delays access to reconstructive options and psychological support. 1