What is the recommended treatment for a patient presenting with Bell's palsy?

Treatment of Bell's Palsy

Prescribe oral corticosteroids (prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper) within 72 hours of symptom onset for all patients 16 years and older, combined with aggressive eye protection measures. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, perform a focused history and physical examination to exclude alternative causes of facial weakness: 1, 2

• Assess forehead involvement: Bell's palsy affects the forehead (lower motor neuron pattern), while stroke spares it (upper motor neuron pattern) 2
• Rule out trauma: temporal bone fracture or surgical injury 2
• Exclude infection, tumor, or stroke: look for bilateral weakness (rare in Bell's palsy), isolated branch paralysis, or other cranial nerve involvement 2
• Verify acute onset: symptoms should develop over 24-72 hours 2

Do NOT obtain routine laboratory testing or diagnostic imaging for typical presentations of Bell's palsy 1, 2

Primary Treatment: Corticosteroids

Timing and Efficacy

Initiate corticosteroids within 72 hours of symptom onset—this is the critical treatment window: 1, 2

• Treatment within 24-48 hours provides the highest benefit, with 66-76% complete recovery rates versus 51-58% without treatment 3
• Treatment between 49-72 hours shows diminishing benefit 3
• No benefit exists beyond 72 hours 2

Dosing Regimens

Choose one of these evidence-based regimens: 2

• Prednisolone 50 mg daily for 10 days (preferred based on landmark trial) 4
• Prednisone 60 mg daily for 5 days, then 5-day taper 2

Evidence Supporting Corticosteroids

The evidence is robust: 2, 4

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo (P<0.001) 4
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo (P<0.001) 4

Antiviral Therapy: Limited Role

Do NOT prescribe antiviral monotherapy—it is ineffective and strongly contraindicated 1, 2

Optional Combination Therapy

You may offer antivirals in addition to corticosteroids within 72 hours, though the added benefit is minimal: 1, 2

• Valacyclovir 1 g three times daily for 7 days 5
• Acyclovir 400 mg five times daily for 10 days (alternative with lower bioavailability) 2, 5

The evidence shows: 2

• Combination therapy: 96.5% complete recovery
• Steroids alone: 89.7% complete recovery
• The difference is small but risks are minimal 2

However, acyclovir alone showed NO benefit in the landmark trial (71.2% recovery versus 75.7% without acyclovir, P=0.50) 4

Eye Protection: Mandatory for All Patients with Impaired Eye Closure

This is a strong recommendation and prevents permanent corneal damage: 1, 2

Daytime Protection

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

Nighttime Protection

• Ophthalmic ointment at bedtime for sustained moisture 2
• Eye taping or patching with careful instruction to avoid corneal abrasion 2
• Moisture chambers using polyethylene covers for severe cases 2

Urgent Ophthalmology Referral Triggers

Refer immediately for: 2

• Complete inability to close the eye
• Eye pain, vision changes, or increasing redness
• Signs of corneal exposure or damage

Follow-Up and Reassessment

Mandatory Reassessment at 3 Months

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months 1, 2

Urgent Reassessment Triggers (At Any Time)

Refer immediately for: 1, 2

• New or worsening neurologic findings: suggests stroke, tumor, or CNS pathology
• Development of ocular symptoms: requires ophthalmology evaluation
• Bilateral facial weakness: not typical of Bell's palsy

Early Follow-Up (1-2 Weeks)

Schedule early reassessment to: 2

• Monitor recovery trajectory
• Reinforce eye protection techniques
• Identify early complications

Special Populations

Children

The evidence for corticosteroids in children is less robust than in adults: 2, 6

• Children have excellent spontaneous recovery rates (up to 90%) 6, 5
• Consider corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers 2, 6
• Eye protection remains mandatory regardless of treatment choice 6

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment: 2

• Pregnant women have up to 90% complete recovery rates 5
• Eye protection is essential and safe in pregnancy 2

Prognosis and Natural History

Understanding the natural history helps set patient expectations: 2

• Incomplete paralysis: up to 94% complete recovery 2
• Complete paralysis: approximately 70% complete recovery within 6 months 2
• 30% may experience permanent facial weakness with muscle contractures 2
• Most patients begin showing recovery within 2-3 weeks 2

Common Pitfalls to Avoid

1. Delaying treatment beyond 72 hours: reduces effectiveness dramatically 2, 3
2. Using antiviral monotherapy: completely ineffective and delays appropriate corticosteroid treatment 1, 2
3. Inadequate eye protection: can lead to permanent corneal damage 2
4. Failing to refer at 3 months: delays access to reconstructive options 2
5. Missing atypical features: bilateral weakness, forehead sparing, or other cranial nerve involvement suggests alternative diagnoses 2
6. Ordering routine labs or imaging: unnecessary for typical presentations and increases costs without benefit 1, 2

Therapies NOT Recommended

Based on current evidence, do NOT routinely recommend: 1, 2

• Physical therapy: no recommendation can be made due to limited evidence (only case series available) 1, 2
• Acupuncture: insufficient evidence to support routine use 1, 2
• Surgical decompression: rarely indicated except in specialized centers for specific cases 2
• Electrodiagnostic testing for incomplete paralysis: not recommended 1