What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Primary Treatment: Oral Corticosteroids

All patients 16 years and older with Bell's palsy should receive oral corticosteroids within 72 hours of symptom onset. 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

The evidence supporting corticosteroids is robust, with 83% recovery at 3 months (versus 63.6% with placebo) and 94.4% recovery at 9 months (versus 81.6% with placebo). 1, 2 This represents a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery based on high-quality randomized controlled trials. 2

Critical Timing Window

Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence of benefit after this window. 1, 3 Delaying treatment reduces effectiveness significantly. 2

Special Populations Requiring Individualized Assessment

For patients with diabetes mellitus, morbid obesity, previous steroid intolerance, or pregnancy, carefully weigh benefits against risks but still strongly consider treatment. 2 Pregnant women should receive corticosteroids with individualized assessment. 1

Antiviral Therapy Considerations

Never prescribe antiviral therapy alone—it is completely ineffective as monotherapy. 1, 2, 4

You may offer combination therapy (oral antivirals plus corticosteroids) within 72 hours as an option, though the benefit is modest. 1, 2 If choosing combination therapy:

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

Some evidence suggests combination therapy may reduce synkinesis rates (96.5% complete recovery versus 89.7% with steroids alone), but the incremental benefit is small. 1, 4

Mandatory Eye Protection

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1, 2

Eye Protection Protocol (Use All Measures):

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Eye patching or taping at night (with careful instruction on proper technique to avoid corneal abrasion) 1, 2
• Sunglasses for outdoor protection against wind and foreign particles 1, 2
• Moisture chambers using polyethylene covers for severe cases 1, 2

Urgent Ophthalmology Referral Indications:

• Severe impairment with complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 1

Pediatric Treatment

Children have better prognosis than adults with spontaneous recovery rates up to 90%. 2, 4 However, evidence for corticosteroid benefit in children is inconclusive. 1, 2

Consider oral corticosteroids on a case-by-case basis with substantial caregiver involvement in shared decision-making. 1, 2 If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper. 1

Follow-Up and Reassessment Requirements

Mandatory Reassessment or Specialist Referral Triggers:

• 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

Expected Recovery Timeline:

• Most patients begin showing recovery within 2-3 weeks 1, 3
• Complete recovery typically occurs within 3-4 months 1, 3
• Approximately 70% with complete paralysis recover fully within 6 months 1, 3
• Patients with incomplete paralysis have recovery rates up to 94% 1

Long-Term Management for Incomplete Recovery:

Refer to facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options including eyelid weights, brow lifts, static facial slings, or dynamic procedures. 1 Screen for depression and provide psychological support. 1

Therapies NOT Recommended

Do not use the following interventions:

• Antiviral monotherapy (completely ineffective) 1, 2, 4
• Surgical decompression (rarely indicated except in specialized centers) 1, 2
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 2
• Physical therapy as primary treatment (limited evidence, though may benefit patients with severe paralysis developing synkinesis) 1, 4

Diagnostic Testing

Do not order routine laboratory testing or diagnostic imaging for typical Bell's palsy. 1, 2 The diagnosis is clinical based on acute unilateral facial weakness involving the forehead with onset under 72 hours. 1

Imaging Indications (MRI with and without contrast):

• Second paralysis on same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1
• No recovery after 3 months 1, 2
• Bilateral facial weakness 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours drastically reduces corticosteroid effectiveness 1, 2
• Using antiviral therapy alone is completely ineffective 1, 2
• Inadequate eye protection can lead to permanent corneal damage 1, 2
• Failing to refer at 3 months for incomplete recovery delays access to reconstructive options 1, 2
• Improper eye taping technique can cause corneal abrasion—provide careful instruction 1, 2
• Restarting or extending corticosteroids beyond the initial 10-day course has no evidence of benefit 3