What is the treatment for Bell's palsy?

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, 2

Recommended Regimens

• 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 Corticosteroids

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 3
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 3
• Number needed to treat is 6 at 3 months and 8 at 9 months 4

Critical Timing Window

• Treatment must be initiated within 72 hours of symptom onset 1, 5, 2
• After 72 hours, steroid benefit is unclear and not supported by high-quality evidence 5
• Clinical trials demonstrating efficacy specifically enrolled patients within this 72-hour window 5

---

Antiviral Therapy Considerations

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

Combination Therapy (Optional)

• May offer oral antivirals in addition to corticosteroids within 72 hours as an option 1, 2
• Valacyclovir 1 g three times daily for 7 days, OR 6
• Acyclovir 400 mg five times daily for 10 days 1, 6
• The added benefit is minimal—corticosteroids remain the cornerstone of treatment 1
• Some evidence suggests modest improvement in synkinesis rates with combination therapy 6, 7

---

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

• 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

• Complete inability to close the eye 1
• Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1
• Development of ocular symptoms at any point during recovery 1, 2

---

Special Populations

Pediatric Patients

• Children have better prognosis with spontaneous recovery rates up to 90% 2, 6
• Evidence for corticosteroid benefit in children is inconclusive 1, 2
• May consider oral corticosteroids on a case-by-case basis with substantial caregiver involvement in shared decision-making 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized assessment of benefits and risks 1, 2
• Eye protection measures are essential and safe in pregnancy 1

Patients with Comorbidities

• Consider careful benefit-risk assessment for patients with diabetes mellitus, morbid obesity, or previous steroid intolerance 2

---

Follow-Up and Reassessment

Mandatory Reassessment or Specialist Referral Triggers

• Incomplete facial recovery at 3 months after symptom onset 1, 5, 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, 2
• Complete recovery typically occurs within 3-4 months 1, 2
• Approximately 70% of patients with complete paralysis recover fully within 6 months 1, 5
• Patients with incomplete paralysis have recovery rates up to 94% 1, 5

Long-Term Management for Incomplete Recovery

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

---

Therapies NOT Recommended

Do not offer the following interventions:

• Antiviral monotherapy (completely ineffective) 1, 2
• Surgical decompression (rarely indicated except in specialized cases) 1, 2
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 2
• Physical therapy (limited evidence, equilibrium of benefit and harm) 1, 2

---

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces corticosteroid effectiveness 5, 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 for incomplete recovery delays access to reconstructive options 1, 2
• Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction 1, 2

---

Diagnostic Considerations

Initial Assessment

• Diagnosis requires acute onset of unilateral facial weakness involving the forehead within 72 hours without identifiable cause 1
• Thorough history and physical examination to exclude trauma, infection, tumor, or stroke 1

When to Order Imaging

• Routine laboratory testing and imaging are NOT recommended for initial diagnosis 1
• MRI with and without contrast is indicated for atypical presentations, no recovery after 3 months, or worsening symptoms 1
• Atypical features requiring imaging include: second paralysis on same side, isolated branch paralysis, other cranial nerve involvement, or bilateral facial weakness 1