What is the treatment for Bell's palsy?

Treatment of Bell's Palsy

Start oral corticosteroids immediately within 72 hours of symptom onset—this is the only proven effective treatment that significantly improves recovery rates from 63.6% to 83% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2

Primary Treatment: Corticosteroids (First-Line, Mandatory)

Prescribe one of these regimens for all patients 16 years and older: 1, 2

• Prednisolone 50 mg daily for 10 days (preferred regimen), OR
• Prednisone 60 mg daily for 5 days, followed by a 5-day taper (10 mg reduction daily) 1, 2

Critical timing: Treatment must begin within 72 hours of symptom onset—delaying beyond this window significantly reduces effectiveness. 1, 2

Special populations requiring individualized assessment: 2

• Diabetes mellitus
• Morbid obesity
• Previous steroid intolerance
• Pregnancy (though treatment is still recommended with careful benefit-risk discussion) 1

Antiviral Therapy: Optional Add-On Only

Never prescribe antivirals alone—they are completely ineffective as monotherapy. 1, 2 The landmark 2007 New England Journal of Medicine trial definitively showed no benefit of acyclovir alone (71.2% recovery vs 75.7% without acyclovir, p=0.50). 3

You may offer combination therapy (antivirals + corticosteroids) within 72 hours as an option: 1, 2

• Valacyclovir 1 g three times daily for 7 days, OR 4, 5
• Acyclovir 400 mg five times daily for 10 days 1, 4

The added benefit is minimal—some studies suggest modest improvement in reducing synkinesis (abnormal facial muscle co-contraction), but corticosteroids remain the cornerstone. 1, 4, 6 One 2003 study showed 87.5% complete recovery with combination therapy versus 68% with no treatment, but this compared against untreated controls, not corticosteroids alone. 5

Eye Protection: Mandatory and Immediate

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

Daytime protection: 1, 2

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

Nighttime protection (critical): 1, 2

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

Urgent ophthalmology referral required for: 1, 2

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

For persistent lagophthalmos beyond 3 months, surgical options include: 1

• Tarsorrhaphy (temporary or permanent partial eyelid closure)
• Eyelid weight implantation
• Botulinum toxin injections

Pediatric Considerations

Children have better prognosis than adults with spontaneous recovery rates up to 90%. 2, 4 However, the evidence for corticosteroid benefit in children is inconclusive—no high-quality pediatric-specific trials exist. 1

Approach for children: 1, 2

• Consider oral corticosteroids on a case-by-case basis with substantial caregiver involvement in shared decision-making
• If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper
• Emphasize to families that most children recover completely without treatment

Follow-Up and Reassessment

Mandatory reassessment or specialist referral is required for: 1, 2, 7

• 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: 1, 7

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

At 3 months, refer to: 1

• Facial nerve specialist or facial plastic surgeon for reconstructive options
• Ophthalmologist for persistent eye closure problems
• Mental health specialist for psychological support (depression risk is elevated)

Therapies NOT Recommended

Do not prescribe or recommend: 1, 2

• Antiviral monotherapy (completely ineffective) 1, 2, 3
• Surgical decompression (rarely indicated except in specialized cases) 1, 2
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1
• Physical therapy (limited evidence, though may help with severe paralysis and developing synkinesis) 1, 4

Diagnostic Testing: What NOT to Do

Do not order routine laboratory testing or imaging for typical Bell's palsy. 1 Diagnosis is clinical, based on acute unilateral facial weakness involving the forehead with onset under 72 hours and no identifiable cause. 1

Order MRI with and without contrast only for atypical features: 1

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

Electrodiagnostic testing (ENoG/EMG): 1

• May offer to patients with complete facial paralysis (not incomplete)
• Most reliable when performed 3-14 days post-onset
• Greater than 10% nerve response amplitude indicates excellent prognosis
• Less than 10% function carries up to 50% risk of incomplete recovery

Common Pitfalls to Avoid

Critical errors that worsen outcomes: 1, 2

• Delaying corticosteroids beyond 72 hours (significantly reduces effectiveness)
• Prescribing antivirals alone (completely ineffective, delays appropriate treatment)
• Inadequate eye protection (leads to permanent corneal damage)
• Failing to refer at 3 months for incomplete recovery (delays access to reconstructive options and psychological support)
• Improper eye taping technique (can cause corneal abrasion—patients need careful instruction)
• Missing atypical features (requires imaging and specialist evaluation to exclude tumor, stroke, Lyme disease, or trauma) 1, 6