What is the recommended treatment for Bell's palsy?

Treatment of Bell's Palsy

Oral corticosteroids initiated within 72 hours of symptom onset are the cornerstone of Bell's palsy treatment and should be prescribed to all patients 16 years and older, combined with aggressive eye protection measures for those with impaired eye closure. 1

Primary Medical Treatment

Corticosteroid therapy must be started within 72 hours of symptom onset to be effective. 1, 2

Recommended Regimen

• Prednisolone 50 mg daily for 10 days OR Prednisone 60 mg daily for 5 days followed by a 5-day taper 1
• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1, 3
• At 9 months, recovery rates reach 94.4% with prednisolone versus 81.6% without treatment 1, 3

Critical Timing Consideration

If a patient presents beyond 72 hours (e.g., at day 5), do NOT initiate corticosteroids as there is no evidence supporting benefit after this window and you expose patients to medication risks without proven efficacy. 2

Antiviral Therapy: Limited Role

Antiviral monotherapy should NEVER be prescribed for Bell's palsy as it is completely ineffective. 1, 2

Optional Combination Therapy

• Antivirals may be added to corticosteroids within 72 hours as an option, though the added benefit is minimal 1
• If used: Valacyclovir 1 g three times daily for 7 days OR Acyclovir 400 mg five times daily for 10 days 1, 4
• Some evidence suggests marginally higher complete recovery rates with combination therapy (96.5%) versus steroids alone (89.7%), but corticosteroids remain the essential component 1

Eye Protection: Mandatory for Impaired Closure

Eye protection is critical to prevent permanent corneal damage and must be implemented immediately for all patients with lagophthalmos. 1

Daytime Protection

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

Nighttime Protection

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

Urgent Ophthalmology Referral Indications

• 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

Special Populations

Children

• Better prognosis than adults with spontaneous recovery rates up to 90-94% 1, 4
• Evidence for corticosteroid benefit in children is inconclusive 1
• Treatment decisions should involve substantial caregiver participation in shared decision-making 1

Pregnant Women

• Should receive oral corticosteroids within 72 hours with individualized risk-benefit assessment 1
• Eye protection measures are essential and safe in pregnancy 1

Follow-Up and Referral Triggers

Mandatory Reassessment or Specialist Referral Required For:

• 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, 5
• Complete recovery typically occurs within 3-4 months 1
• 70% of patients with complete paralysis recover fully within 6 months even without treatment 1, 6
• Patients with incomplete paralysis have recovery rates up to 94% 1

Diagnostic Testing: Generally NOT Recommended

Routine laboratory testing and diagnostic imaging are NOT recommended for initial Bell's palsy diagnosis. 1

When Imaging IS Indicated:

• Atypical presentations (bilateral weakness, isolated branch paralysis, other cranial nerve involvement) 1
• No recovery after 3 months 1
• Worsening symptoms 1
• MRI with and without contrast is the imaging test of choice when indicated 1

Electrodiagnostic Testing

• May be offered to patients with complete facial paralysis (not incomplete) 1
• Most reliable when performed 3-14 days post-onset 1
• Greater than 10% nerve response amplitude indicates excellent prognosis 1

Therapies NOT Recommended

• Antiviral monotherapy - completely ineffective 1, 2
• Surgical decompression - rarely indicated except in specialized circumstances 1
• Acupuncture - no recommendation can be made due to poor-quality trials 1
• Physical therapy - limited evidence, though may be beneficial for severe paralysis with developing synkinesis 1, 4

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces or eliminates corticosteroid effectiveness 1, 2
• Starting corticosteroids after 72 hours exposes patients to medication risks without proven benefit 2
• Using antiviral therapy alone is ineffective and delays appropriate treatment 1, 2
• Inadequate eye protection can lead to permanent corneal damage 1, 2
• Failing to refer at 3 months with incomplete recovery delays access to reconstructive options 1
• Improper eye taping technique can cause corneal abrasion 1