What is the recommended treatment for Bell's palsy?

Bell's Palsy Treatment

Start oral corticosteroids (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with 5-day taper) within 72 hours of symptom onset for all patients 16 years and older, and immediately implement aggressive eye protection for anyone with impaired eye closure. 1, 2

Critical Time Window for Treatment

• Corticosteroids are only effective when initiated within 72 hours of symptom onset - this is a hard deadline based on all clinical trial evidence 1, 2
• Treatment started within 24-48 hours shows the highest recovery rates (66-76% complete recovery) compared to 51-58% without treatment 3
• After 72 hours, steroids provide minimal benefit and expose patients to unnecessary medication risks - focus shifts entirely to supportive care 1

Corticosteroid Regimen

• Prednisolone 50 mg daily for 10 days (preferred) OR Prednisone 60 mg daily for 5 days followed by 5-day taper 2, 4
• Evidence demonstrates 83% recovery at 3 months versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 2, 5
• Higher doses (≥80 mg daily) may provide additional benefit with acceptable safety profile, though this requires further validation 6

Antiviral Therapy Decision

• Never prescribe antiviral monotherapy - it is completely ineffective 2, 4
• May add valacyclovir 1g three times daily for 7 days OR acyclovir 400mg five times daily for 10 days to corticosteroids within 72 hours as optional combination therapy 2, 7
• Combination therapy shows modest improvement (96.5% complete recovery versus 89.7% with steroids alone) with minimal additional risk 4
• The benefit is small but risks are negligible, making this a reasonable option for severe cases 2

Mandatory Eye Protection Protocol

Implement immediately for all patients with impaired eye closure - this is non-negotiable to prevent permanent corneal damage 2, 4

Daytime Protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 2, 4
• Sunglasses outdoors for wind and particle protection 2, 4

Nighttime Protection:

• Ophthalmic ointment at bedtime for sustained moisture 2, 4
• Eye patching or taping (requires careful instruction on proper technique to avoid corneal abrasion) 2, 4
• Moisture chambers using polyethylene covers for severe cases 2, 4

Urgent Ophthalmology Referral Needed For:

• Complete inability to close the eye 4
• Eye pain, vision changes, redness, discharge, or foreign body sensation 4
• Any signs of corneal exposure or damage 4

Special Population Considerations

Children:

• Have better prognosis with up to 90% spontaneous recovery rates 2, 7
• Evidence for corticosteroid benefit is inconclusive in pediatrics 2, 4
• May consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days with 5-day taper for severe/complete paralysis cases after shared decision-making with caregivers 4

Pregnancy:

• Treat with oral corticosteroids within 72 hours using standard adult dosing 4
• Combination therapy with antivirals may be considered on case-by-case basis 4
• Eye protection protocol remains identical 4

Patients with Diabetes, Morbid Obesity, or Previous Steroid Intolerance:

• Requires careful benefit-risk assessment but treatment should still be offered within 72 hours 2

Follow-Up and Referral Algorithm

Mandatory Reassessment or Specialist Referral Required For:

• Incomplete facial recovery at 3 months after symptom onset 2, 4
• New or worsening neurologic findings at any point 2, 4
• Development of ocular symptoms at any point 2, 4

Expected Recovery Timeline:

• Most patients begin showing recovery within 2-3 weeks 1, 2
• Complete recovery typically occurs within 3-4 months 2, 4
• 70% of patients with complete paralysis recover fully within 6 months even without treatment 1, 2
• Patients with incomplete paralysis have up to 94% recovery rates 1, 2

Imaging Indications (MRI with and without contrast):

• Second paralysis on same side 4
• Isolated branch paralysis 4
• Other cranial nerve involvement 4
• No recovery after 3 months 4

Therapies NOT Recommended

• Antiviral monotherapy - completely ineffective 2, 4
• Surgical decompression - rarely indicated except in specialized centers 4
• Acupuncture - poor quality evidence, no recommendation possible 4
• Physical therapy - limited evidence, though may be beneficial in severe cases 4, 7

Critical Pitfalls to Avoid

• Starting steroids beyond 72 hours - provides minimal benefit and exposes patients to unnecessary risks 1, 2
• Inadequate eye protection - can lead to permanent corneal damage requiring surgical intervention 2, 4
• Improper eye taping technique - can cause corneal abrasion; patients must receive careful instruction 2, 4
• Failing to refer at 3 months for incomplete recovery - delays access to reconstructive options including eyelid weights, nerve transfers, and facial slings 4
• Missing atypical features - bilateral weakness, isolated branch paralysis, or other cranial nerve involvement requires imaging and specialist evaluation 4