What is the recommended treatment for a patient with Bell's palsy, considering their underlying medical history, such as diabetes or history of stroke?

Treatment of Bell's Palsy

Prescribe oral corticosteroids 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, and implement immediate eye protection measures for patients with impaired eye closure. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis through history and physical examination to exclude alternative causes of facial paralysis: 1, 2

• Verify unilateral facial weakness involving the forehead (inability to raise eyebrow or wrinkle forehead on affected side distinguishes this from stroke, which spares the forehead) 3
• Confirm rapid onset within 72 hours 2, 4
• Exclude other neurological deficits such as limb weakness, sensory changes, diplopia, dysphagia, or other cranial nerve involvement (presence of these suggests stroke or other pathology, not Bell's palsy) 3
• Do not obtain routine laboratory testing or imaging for typical presentations 1, 2

Primary Medical Treatment

Corticosteroid Therapy (Mandatory)

Initiate corticosteroids immediately if presenting within 72 hours of symptom onset: 1, 2

• Prednisolone 50 mg orally daily for 10 days, OR 2
• Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over the next 5 days 2

Evidence supporting this recommendation: Prednisolone achieves 83% complete recovery at 3 months versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo. 2, 5 This benefit applies regardless of baseline severity—even patients with severe paralysis show 51% recovery with prednisolone versus 31% without treatment. 6

Do not initiate corticosteroids beyond 72 hours of symptom onset, as there is no evidence of benefit after this window. 2

Antiviral Therapy (Optional, Minimal Benefit)

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

You may offer combination therapy with oral antivirals plus corticosteroids within 72 hours, though the added benefit is small: 1, 2

• Valacyclovir 1000 mg orally three times daily for 7 days, OR 2
• Acyclovir 400 mg orally five times daily for 10 days (requires more frequent dosing due to lower bioavailability) 2

The evidence shows 96.5% complete recovery with combination therapy versus 89.7% with steroids alone—a modest 6.8% absolute benefit. 2 Given minimal risks, this may be offered based on shared decision-making, but corticosteroids remain the cornerstone of treatment. 1, 2

Eye Protection (Mandatory for Impaired Eye Closure)

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

Daytime Protection

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

Nighttime Protection

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

Urgent Ophthalmology Referral Indications

• Complete inability to close the eye 2
• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Signs of corneal exposure or damage 2

Special Population Considerations

Patients with Diabetes or History of Stroke

Treat identically to the general population—there is no evidence requiring modification of the standard corticosteroid regimen for patients with diabetes or prior stroke. 1, 2 However, monitor blood glucose more closely in diabetic patients receiving corticosteroids. The priority remains preventing permanent facial nerve damage, which outweighs concerns about temporary hyperglycemia.

Pregnant Women

Prescribe oral corticosteroids within 72 hours using the same regimen, with individualized assessment of benefits versus risks. 2 The evidence for corticosteroid efficacy applies to pregnant women, and eye protection measures are essential and safe in pregnancy. 2

Children Under 16 Years

Consider oral corticosteroids on an individualized basis (prednisolone 1 mg/kg/day, maximum 50-60 mg, for 5 days followed by 5-day taper), involving caregivers in shared decision-making. 2 Children have better prognosis with higher spontaneous recovery rates (up to 94%), but the benefit of corticosteroids in pediatrics remains unproven. 2 Do not initiate treatment beyond 72 hours. 2

Therapies NOT Recommended

• Do not prescribe antiviral monotherapy 1, 2
• Do not perform routine laboratory testing or diagnostic imaging for typical presentations 1, 2
• Do not perform electrodiagnostic testing for patients with incomplete facial paralysis 1
• No recommendation can be made for acupuncture—evidence is poor quality with indeterminate benefit-harm ratio 1, 2
• No recommendation can be made for physical therapy—limited evidence shows no proven benefit over spontaneous recovery 1, 2
• Do not perform surgical decompression except in rare, highly selected cases at specialized centers 1, 2

Follow-Up and Reassessment

Mandatory reassessment or referral to a facial nerve specialist is required for: 1, 2

• New or worsening neurologic findings at any point 2
• Development of ocular symptoms at any point 2
• Incomplete facial recovery at 3 months after symptom onset 1, 2

At the 3-month mark, if recovery is incomplete, refer to a facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options (static procedures like eyelid weights, brow lifts, or dynamic procedures like nerve transfers). 2 Also refer to ophthalmology for persistent eye closure problems and consider screening for depression. 2

Prognosis

Patients with incomplete paralysis at presentation have excellent prognosis with up to 94% complete recovery. 2

Patients with complete paralysis have approximately 70% complete recovery within 6 months. 2 Electrodiagnostic testing showing greater than 10% nerve response amplitude predicts excellent prognosis, while less than 10% function carries up to 50% risk of incomplete recovery. 2

Approximately 30% of patients may experience permanent facial weakness with muscle contractures. 2

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates the proven benefit 2
• Prescribing antiviral therapy alone is ineffective and delays appropriate treatment 2
• Failing to implement eye protection can lead to permanent corneal damage 2
• Missing stroke by not testing forehead function—stroke spares the forehead due to bilateral cortical innervation, while Bell's palsy affects the entire ipsilateral face including forehead 3
• Failing to refer at 3 months delays access to reconstructive options and psychological support 2