What are the treatment options for Bell’s palsy?

Treatment Options for Bell's Palsy

Primary Treatment: Oral Corticosteroids

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy. 1, 2

The recommended regimens are:

• Prednisolone 50 mg daily for 10 days, OR 1, 2
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

This recommendation is based on strong evidence showing 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% without treatment. 2, 3 The 72-hour window is critical because clinical trials demonstrating steroid efficacy specifically enrolled patients within this timeframe, and no high-quality evidence supports treatment beyond this period. 1

Do not initiate corticosteroids after 72 hours of symptom onset, as this provides minimal benefit and exposes patients to medication risks without proven efficacy. 1

Combination Therapy: Corticosteroids Plus Antivirals

Consider adding oral antiviral therapy to corticosteroids within 72 hours of symptom onset, particularly for patients with severe or complete paralysis. 2, 4

Recommended antiviral regimens include:

• Valacyclovir 1 g three times daily for 7 days, OR 4, 5
• Acyclovir 400 mg five times daily for 10 days 4

The evidence for combination therapy is mixed. One study showed 96.5% complete recovery with combination therapy versus 89.7% with steroids alone 2, and another demonstrated 87.5% complete recovery with valacyclovir plus prednisone versus 68% with no treatment. 5 However, the largest randomized controlled trial found no additional benefit of acyclovir when added to prednisolone. 3 The benefit appears small but risks are minimal. 2

Never prescribe antiviral monotherapy, as it is completely ineffective without corticosteroids. 1, 2, 4, 3

Essential Eye Protection

Implement comprehensive eye protection immediately for all patients with impaired eye closure to prevent corneal damage, which can lead to permanent vision loss. 1, 2

Daytime Protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Sunglasses for outdoor protection against wind and foreign particles 1, 2

Nighttime Protection:

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Moisture chambers using polyethylene covers for severe cases 1, 2

Urgent Ophthalmology Referral Indications:

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

Special Populations

Children

Consider oral corticosteroids on an individualized basis with substantial caregiver participation in shared decision-making. 2, 6 Children have better prognosis than adults with up to 90% complete recovery rates 4, but no high-quality pediatric-specific trials exist to prove steroid benefit. 2 If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper, only within 72 hours of symptom onset. 2

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours on an individualized basis with careful assessment of benefits and risks. 1, 2 Combination therapy with antivirals may be considered individually. 2

Follow-Up and Referral Criteria

Mandatory reassessment or specialist referral is required for: 1, 2

• Incomplete facial recovery at 3 months after symptom onset 1, 2
• New or worsening neurologic findings at any point 1, 2
• Development of ocular symptoms at any point 1, 2

Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 2 Approximately 70% of patients with complete paralysis recover fully within 6 months even without treatment, while those with incomplete paralysis have up to 94% recovery rates. 1, 2

Therapies NOT Recommended

Do not offer the following treatments: 2

• Antiviral monotherapy (completely ineffective) 1, 2, 4, 3
• Routine laboratory testing or diagnostic imaging for typical presentations 2
• Surgical decompression except in rare specialized cases 2
• Acupuncture (no recommendation possible due to poor-quality trials) 2
• Physical therapy as primary treatment (limited evidence, though may benefit patients with severe paralysis and developing synkinesis) 2, 6, 4

Common Pitfalls to Avoid

• Starting treatment beyond 72 hours reduces effectiveness dramatically 1
• Failing to provide adequate eye protection can lead to permanent corneal damage 1, 2
• Not referring patients with incomplete recovery at 3 months delays access to reconstructive options 2
• Using antiviral therapy alone is ineffective and wastes resources 1, 2, 3