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—this is the only proven effective treatment that significantly improves facial nerve recovery. 1, 2
Recommended Corticosteroid Regimens
Choose one of these evidence-based options:
- 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
The benefit is substantial and well-established:
- 83% recovery at 3 months with prednisolone vs 63.6% with placebo 1
- 94.4% recovery at 9 months with prednisolone vs 81.6% with placebo 1
- Treatment must be initiated within 72 hours—no benefit exists beyond this window 1, 2
Antiviral Therapy: Limited Role
Never prescribe antiviral therapy alone—it is completely ineffective as monotherapy. 1, 2, 3
Optional Combination Therapy
You may offer antiviral therapy in addition to corticosteroids within 72 hours, though the added benefit is minimal:
- Valacyclovir 1 g three times daily for 7 days, OR 3
- Acyclovir 400 mg five times daily for 10 days 1, 3
The combination may provide a small additional benefit (96.5% complete recovery vs 89.7% with steroids alone), but corticosteroids remain the cornerstone of treatment 1. Some evidence suggests combination therapy may reduce synkinesis rates 3.
Eye Protection: Mandatory for All Patients with Impaired Eye Closure
Implement aggressive eye protection immediately to prevent permanent corneal damage—this is non-negotiable for patients who cannot fully close their eyelid. 1, 2
Eye Protection Protocol
Apply these measures based on severity:
For all patients with lagophthalmos:
- Lubricating eye drops every 1-2 hours while awake 1, 2
- Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
- Sunglasses outdoors to protect against wind and foreign particles 1, 2
For moderate to severe impairment:
- Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1, 2
- Moisture chambers using polyethylene covers for nighttime protection 1
For severe impairment with complete inability to close the eye:
- Urgent ophthalmology referral for evaluation of surgical options 1
- Consider tarsorrhaphy (partial eyelid closure) or eyelid weight implantation for persistent lagophthalmos 1
Warning Signs Requiring Urgent Ophthalmology Referral
Refer immediately if the patient develops:
- Eye pain, vision changes, or increasing redness 1
- Discharge or sensation of foreign body 1
- Increasing irritation despite protection measures 1
Diagnosis and Initial Assessment
Bell's palsy is a diagnosis of exclusion requiring careful evaluation to rule out alternative causes 1, 2.
Key Diagnostic Features
Confirm these characteristics:
- Acute onset of unilateral facial weakness developing over 24-72 hours 1, 2
- Forehead involvement (distinguishes from stroke, which spares the forehead) 1, 2
- No other neurologic abnormalities 3
Red Flags Suggesting Alternative Diagnosis
Order MRI with and without contrast if you see:
- Bilateral facial weakness 1
- Isolated branch paralysis (not affecting entire side of face) 1
- Other cranial nerve involvement 1
- Progressive weakness beyond 3 weeks 1
- Recurrent paralysis on the same side 1
- Forehead sparing (suggests central lesion/stroke) 2, 4
- Associated anomia or language changes (suggests stroke) 4
Testing Recommendations
Do NOT order routine laboratory testing or imaging for typical Bell's palsy presentations—this increases costs without benefit 1, 2. Imaging is only indicated for atypical features as listed above 1.
Follow-Up and Reassessment
Mandatory Reassessment Timeline
Refer to a facial nerve specialist at 3 months if facial recovery is incomplete—this is the critical decision point for reconstructive options 1, 2.
Urgent Reassessment Triggers (At Any Time)
Refer immediately if the patient develops:
- New or worsening neurologic findings (suggests alternative diagnosis like tumor or stroke) 1, 2, 4
- Ocular symptoms (requires urgent ophthalmology evaluation) 1, 2
- Progressive weakness beyond 3 weeks (not typical for Bell's palsy) 1
Early Follow-Up Schedule
- Initial visit within 72 hours for treatment initiation and eye care education 1
- Follow-up at 1-2 weeks to assess recovery trajectory and reinforce eye protection 1
- Mandatory reassessment at 3 months for all patients with incomplete recovery 1, 2
Special Populations
Children
Children have better prognosis than adults with higher rates of spontaneous recovery (up to 90%), but the benefit of corticosteroid treatment remains inconclusive in pediatrics. 1, 3
- Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers 1, 2
- No high-quality pediatric-specific trials exist to guide treatment 1
- Most children recover completely without treatment 1
Pregnant Women
Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment—pregnancy does not contraindicate treatment 1, 2.
- Eye protection measures are essential and safe in pregnancy 1
- Combination therapy with antivirals may be considered on an individualized basis 1
Prognosis and Natural History
Understanding the natural history helps set realistic patient expectations:
Recovery Rates
- Patients with incomplete paralysis: up to 94% complete recovery 1, 3
- Patients with complete paralysis: approximately 70% complete recovery within 6 months 1, 3
- Most patients begin showing recovery within 2-3 weeks 1
- Complete recovery typically occurs within 3-4 months 1
Long-Term Outcomes
- Approximately 30% may experience permanent facial weakness with muscle contractures 1
- Patients with persistent paralysis experience significant psychosocial dysfunction requiring active management 1
Therapies NOT Recommended
Do not offer these interventions:
- Acupuncture: No recommendation can be made due to poor-quality trials 1, 5
- Physical therapy: No proven benefit over spontaneous recovery, though may be beneficial in severe paralysis 1, 5, 3
- Surgical decompression: Rarely indicated except in specialized centers for specific cases 1
- Antiviral monotherapy: Completely ineffective and strongly contraindicated 1, 2, 3
Common Pitfalls to Avoid
- Delaying corticosteroid treatment beyond 72 hours dramatically reduces effectiveness 1, 2
- Prescribing 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 delays access to reconstructive options and psychological support 1
- Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2
- Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2