Treatment of 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
The recommended regimens are:
- Prednisolone 50 mg daily for 10 days, OR 1
- Prednisone 60 mg daily for 5 days followed by a 5-day taper 1
The evidence supporting corticosteroids is robust, with 83% recovery at 3 months compared to 63.6% with placebo, and 94.4% recovery at 9 months compared to 81.6% with placebo. 1 This represents a strong recommendation based on high-quality randomized controlled trials. 2
Exceptions to Corticosteroid Use
Consider individualized assessment for patients with:
- Diabetes mellitus 2
- Morbid obesity 2
- Previous steroid intolerance 2
- Pregnancy (requires careful benefit-risk assessment) 2, 1
Antiviral Therapy Considerations
Do NOT prescribe antiviral therapy alone—it is ineffective as monotherapy. 2, 1
You may offer combination therapy (oral antivirals plus corticosteroids) within 72 hours of symptom onset as an option, though the benefit is small. 2, 1 The evidence shows equilibrium between benefit and harm, with some trials suggesting modest improvement (96.5% complete recovery with combination therapy versus 89.7% with steroids alone), but large high-quality trials have not confirmed significant benefit. 2
If choosing combination therapy, use:
This decision requires shared decision-making with the patient, as the potential benefit is small and the evidence is not definitive. 2
Mandatory Eye Protection
Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent corneal damage. 1
Eye Protection Protocol:
- Lubricating ophthalmic drops every 1-2 hours while awake 1
- Ophthalmic ointment at bedtime for sustained moisture retention 1
- Eye patching or taping at night (with careful instruction on proper technique to avoid corneal abrasion) 1
- Sunglasses for outdoor protection against wind and foreign particles 1
- Moisture chambers using polyethylene covers for severe cases 1
Urgent Ophthalmology Referral Indications:
Refer immediately if the patient develops:
- Eye pain 1
- Changes in vision 1
- Eye redness or discharge 1
- Sensation of foreign body 1
- Complete inability to close the eye 1
This is a strong recommendation based on expert opinion with a preponderance of benefit over harm. 2
Pediatric Considerations
Children have better prognosis than adults, with spontaneous recovery rates up to 90%. 3 However, the evidence for corticosteroid benefit in children is inconclusive, as no high-quality pediatric-specific trials exist. 1
You may consider oral corticosteroids in children on a case-by-case basis with substantial caregiver involvement in decision-making. 1 If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper, initiated within 72 hours of symptom onset. 1
Follow-Up and Reassessment
Mandatory Reassessment or Specialist Referral:
- Incomplete facial recovery at 3 months after symptom onset 1
- New or worsening neurologic findings at any point 1
- Development of ocular symptoms at any point 1
Expected Recovery Timeline:
- Most patients begin showing recovery within 2-3 weeks 1
- Complete recovery typically occurs within 3-4 months 1
- Approximately 70% of patients with complete paralysis recover fully within 6 months 1
- Patients with incomplete paralysis have recovery rates up to 94% 1
Imaging Indications:
Do NOT order routine laboratory testing or imaging for typical Bell's palsy. 1 However, obtain MRI with and without contrast if:
- Second paralysis on the same side (recurrent Bell's palsy) 1
- Isolated branch paralysis 1
- Other cranial nerve involvement 1
- No recovery after 3 months 1
- Bilateral facial weakness 1
Therapies NOT Recommended
Do NOT prescribe:
- Antiviral monotherapy (ineffective) 2, 1
- Surgical decompression (rarely indicated except in specialized centers) 1
No recommendation can be made for:
- Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1
- Physical therapy (limited evidence, though may be beneficial in severe paralysis with developing synkinesis) 1, 3
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours reduces effectiveness of corticosteroid therapy 1
- Using antiviral therapy alone is ineffective and should never be prescribed 2, 1
- Inadequate eye protection can lead to permanent corneal damage, especially in patients with complete inability to close the eye 1
- Failing to refer at 3 months for incomplete recovery delays access to reconstructive options 1
- Missing atypical features (recurrent paralysis, bilateral involvement, other cranial nerve deficits) that require imaging and specialist evaluation 1
- Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 1