What is the treatment for Bell's palsy?

Treatment for Bell's Palsy

Start oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older—this is the single most important intervention that significantly improves facial nerve recovery. 1, 2

Primary Treatment: Corticosteroids

Prescribe one of these regimens immediately:

• 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

Evidence supporting this approach:

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1, 2
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1, 2
• Treatment beyond 72 hours loses effectiveness—do not delay 2, 3

Antiviral Therapy Considerations

Do NOT prescribe antivirals alone—they are completely ineffective as monotherapy. 2, 4

You may offer combination therapy (corticosteroids + antivirals) within 72 hours as an option:

• Valacyclovir 1 g three times daily for 7 days, OR 4
• Acyclovir 400 mg five times daily for 10 days 4
• Some evidence suggests modest improvement in recovery rates (96.5% vs 89.7% with steroids alone) and potential reduction in synkinesis 2, 5
• The benefit is small but risks are minimal 1

Mandatory Eye Protection (Start Immediately)

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

Daytime protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1, 2
• Sunglasses outdoors to protect against wind and foreign particles 1, 2

Nighttime protection:

• Ophthalmic ointment at bedtime for sustained moisture 1, 2
• Eye patching or taping (instruct carefully on proper technique to avoid corneal abrasion) 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1, 2

Urgent ophthalmology referral if:

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1

Special Populations

Children:

• Better prognosis than adults with spontaneous recovery rates up to 90% 2, 4
• Evidence for corticosteroid benefit is inconclusive in pediatrics 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 5-day taper 1

Pregnant women:

• Treat with oral corticosteroids within 72 hours using individualized benefit-risk assessment 1
• Recovery rates approach 90% 4
• Combination therapy with antivirals may be considered on an individualized basis 1

Patients with diabetes, morbid obesity, or previous steroid intolerance:

• Perform careful benefit-risk assessment but generally still treat 2

Follow-Up and Reassessment

Mandatory reassessment or specialist referral for: 1, 2

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

Expected recovery timeline:

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

At 3 months, if incomplete recovery:

• Refer to facial nerve specialist or facial plastic surgeon for reconstructive options 1
• Refer to ophthalmology for persistent eye closure problems 1
• Screen for depression and provide psychological support 1

Diagnostic Testing (What NOT to Do)

Do NOT order routine laboratory testing or imaging for typical Bell's palsy. 1, 2

Order MRI with and without contrast only if: 1

• Second paralysis on same side
• Isolated branch paralysis (not all facial muscles affected)
• Other cranial nerve involvement
• No recovery after 3 months
• Worsening symptoms

Therapies NOT Recommended

Do not offer these interventions: 1, 2

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

Critical Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates their effectiveness 2, 3
• Using antivirals alone is completely ineffective—never prescribe as monotherapy 2, 4
• Inadequate eye protection leads to permanent corneal damage 1, 2
• Improper eye taping technique can cause corneal abrasion—instruct patients carefully 1
• Failing to refer at 3 months for incomplete recovery delays access to reconstructive options 1
• Missing atypical features (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) requires imaging and specialist evaluation 1