What is the recommended medical management for Bell's palsy?

Medical Management for Bell's Palsy

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

First-Line Treatment: Corticosteroids

Initiate 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. 1

The evidence for corticosteroids is robust:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 2
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 2
• Maximum benefit occurs when treatment starts within 48 hours of onset 3
• Treatment between 49-72 hours shows diminished but still meaningful benefit 3

Critical pitfall: Do not delay treatment beyond 72 hours—effectiveness drops significantly after this window. 1

Antiviral Therapy Considerations

Do not prescribe antiviral monotherapy—it is ineffective. 1, 2

However, you may offer combination therapy (oral corticosteroid + antiviral) within 72 hours as an option:

• Valacyclovir 1 g three times daily for 7 days 4
• OR acyclovir 400 mg five times daily for 10 days 4

The benefit of adding antivirals to steroids is small but risks are minimal 1. One study showed 96.5% complete recovery with combination therapy versus 89.7% with steroids alone 1, though the landmark 2007 trial found no additional benefit 2. Some evidence suggests combination therapy may reduce synkinesis rates 4.

Eye Protection (Mandatory for All Patients)

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

Daytime Protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors for wind and particle protection 1

Nighttime Protection:

• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching with careful instruction on proper technique 1
• Consider moisture chambers (polyethylene covers) for severe cases 1

Urgent Ophthalmology Referral Needed For:

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

Critical pitfall: Improper eye taping can cause corneal abrasion—ensure patients receive careful instruction. 1

Special Populations

Children:

• Better prognosis with up to 94% spontaneous recovery rates 1
• Evidence for corticosteroid benefit is inconclusive in pediatrics 1
• May consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for severe cases with caregiver involvement in shared decision-making 1
• Inform families that most children recover completely without treatment 1

Pregnant Women:

• Treat with oral corticosteroids within 72 hours on an individualized basis after careful risk-benefit assessment 1
• Combination therapy with antivirals may be considered individually 1
• Eye protection remains essential 1

Diagnostic Testing

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

Order MRI with and without contrast only for:

• Atypical features (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) 1
• No recovery after 3 months 1
• Worsening symptoms 1
• Second paralysis on same side 1

Follow-Up and Reassessment

Mandatory reassessment or specialist referral at 3 months if incomplete facial recovery persists. 1

Immediate Referral to Facial Nerve Specialist Required For:

• New or worsening neurologic findings at any point 1
• Development of ocular symptoms at any point 1
• Incomplete recovery at 3 months 1

Expected Recovery Timeline:

• Most patients begin recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• 70% of patients with complete paralysis recover fully within 6 months 1
• 94% of patients with incomplete paralysis recover fully 1
• 30% may experience permanent facial weakness with contractures 1

Therapies NOT Recommended

Do not prescribe:

• Antiviral monotherapy (ineffective) 1, 2
• Corticosteroids beyond the initial 10-day course 5
• Routine physical therapy (limited evidence, though may benefit severe cases with developing synkinesis) 1, 4
• Acupuncture (insufficient evidence) 1
• Surgical decompression (rarely indicated except in specialized centers) 1

Long-Term Management for Incomplete Recovery

For patients with persistent deficits at 3 months:

• Refer to facial nerve specialist for reconstructive options (eyelid weights, brow lifts, nerve transfers) 1
• Ophthalmology referral for persistent lagophthalmos (consider tarsorrhaphy or eyelid weight implantation) 1
• Screen for depression and provide psychological support 1
• Monitor for synkinesis development 6