What is the recommended treatment for acute Bell's palsy?

Treatment for Acute Bell's Palsy

Oral corticosteroids should be prescribed within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy, using prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Primary Medical Treatment

• Corticosteroids are the only proven effective treatment and significantly improve facial nerve recovery, 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
• Treatment must be initiated within 72 hours of symptom onset—delaying beyond this window eliminates the therapeutic benefit 1
• The recommended regimen is prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 3

Antiviral Therapy Considerations

• Antiviral monotherapy should never be prescribed—it is completely ineffective 1, 4, 2
• Combination therapy (oral corticosteroids plus antivirals) may be offered within 72 hours as an option, though the added benefit is minimal 1, 3
• If combination therapy is chosen, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 1, 3
• The benefit of adding antivirals is small (96.5% complete recovery with combination versus 89.7% with steroids alone), but risks are minimal 1

Essential Eye Protection

Aggressive eye protection is mandatory for all patients with impaired eye closure to prevent corneal damage. 1

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use ophthalmic ointment at bedtime for sustained moisture retention 1
• Implement eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1
• Wear sunglasses outdoors for protection against wind and foreign particles 1
• Consider moisture chambers using polyethylene covers for severe cases 1
• Refer urgently to ophthalmology if complete inability to close the eye or signs of corneal exposure develop 1

Diagnostic Approach

• Bell's palsy is a clinical diagnosis requiring exclusion of other causes through thorough history and physical examination 1
• Routine laboratory testing and diagnostic imaging are NOT recommended for typical Bell's palsy presentations 1
• Key diagnostic features include acute onset (within 72 hours), unilateral facial weakness involving the forehead, and absence of other neurologic abnormalities 1, 3
• Red flags requiring imaging (MRI with and without contrast) include: second paralysis on same side, isolated branch paralysis, other cranial nerve involvement, bilateral facial weakness, or no recovery after 3 months 1

Special Populations

Children

• Children have better prognosis with higher spontaneous recovery rates (up to 90%) compared to adults 3
• Evidence for corticosteroid benefit in children is inconclusive, but treatment may be considered for severe cases with substantial caregiver participation in decision-making 1
• If treating, use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper 1

Pregnant Women

• Pregnant women should be treated with oral corticosteroids within 72 hours using careful individualized risk-benefit assessment 1
• Eye protection measures are essential and safe in pregnancy 1

Follow-Up and Referral Criteria

• Reassess or refer to a facial nerve specialist if incomplete facial recovery persists at 3 months after symptom onset 1
• Immediate referral required for new or worsening neurologic findings at any point 1
• Urgent ophthalmology referral needed for development of ocular symptoms at any point 1
• Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months 1

Prognosis

• Patients with incomplete paralysis at presentation have excellent prognosis with up to 94% complete recovery 1, 3
• Patients with complete paralysis have approximately 70% complete recovery within 6 months 1
• With early corticosteroid treatment, recovery rates improve significantly to 94.4% at 9 months 1, 2
• Approximately 30% of patients may experience permanent facial weakness with muscle contractures 1

Common Pitfalls to Avoid

• Never prescribe antiviral therapy alone—it is ineffective and delays appropriate corticosteroid treatment 1, 2
• Do not delay treatment beyond 72 hours, as effectiveness diminishes significantly 1
• Do not neglect eye protection even if the patient's primary complaint is facial weakness rather than eye symptoms 1
• Do not fail to test forehead function during examination, as forehead sparing indicates a central (stroke) rather than peripheral cause 1
• Do not restart or extend corticosteroid therapy beyond the initial 10-day course—evidence supports only the initial treatment window 5

Therapies NOT Recommended

• Acupuncture: no recommendation can be made due to poor-quality trials 1, 4
• Physical therapy: no recommendation can be made due to limited evidence, though may be beneficial for severe paralysis with developing synkinesis 1, 3
• Surgical decompression: rarely indicated except in specialized circumstances 1