What is the treatment for a patient diagnosed with Bell’s palsy?

Treatment of Bell's Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset—prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—as this is the only proven effective treatment that significantly improves facial nerve recovery. 1

Immediate Management (Within 72 Hours)

Corticosteroid Therapy (First-Line, Mandatory)

• Start oral corticosteroids immediately for all patients 16 years and older with Bell's palsy presenting within 72 hours of symptom onset 1
• Use either:
  • Prednisolone 50 mg orally daily for 10 days (no taper needed), OR 1
  • Prednisone 60 mg orally daily for 5 days, then taper over 5 days 1
• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 1
• Do not initiate corticosteroids beyond 72 hours—there is no evidence of benefit after this window 1

Antiviral Therapy (Optional, Minimal Benefit)

• Never prescribe antiviral monotherapy—it is completely ineffective 1, 2
• May offer combination therapy with valacyclovir 1 g orally three times daily for 7 days PLUS corticosteroids within 72 hours 1, 2
• Alternative: acyclovir 400 mg orally five times daily for 10 days PLUS corticosteroids 1
• The added benefit is minimal (96.5% complete recovery with combination versus 89.7% with steroids alone), but risks are low 1

Eye Protection (Critical, Mandatory)

• Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage 1
• Daytime regimen:
  • Lubricating ophthalmic drops every 1-2 hours while awake 1
  • Sunglasses outdoors for wind and particle protection 1
• Nighttime regimen:
  • Ophthalmic ointment at bedtime for sustained moisture 1
  • Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
  • Consider moisture chambers using polyethylene covers for severe cases 1
• Refer urgently to ophthalmology if complete inability to close eye or signs of corneal exposure/damage 1

Special Populations

Pediatric Patients

• Children have better prognosis with up to 90% spontaneous recovery rates 2
• Evidence for corticosteroid benefit in children is inconclusive 1
• May consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper for severe/complete paralysis, but only with substantial caregiver participation in shared decision-making 1
• Clearly inform families that most children recover completely without treatment and steroid benefit remains unproven in pediatrics 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Pregnancy is a risk factor for Bell's palsy, but corticosteroids can be used safely 2
• Eye protection measures are essential and safe in pregnancy 1

Diagnostic Considerations

Confirm Diagnosis (Exclusion of Other Causes)

• Bell's palsy is a diagnosis of exclusion—no identifiable cause for acute unilateral facial nerve paresis/paralysis with onset <72 hours 1, 3
• Must involve forehead weakness (distinguishes from stroke, which spares forehead) 1, 3
• Exclude: trauma, infection (Lyme disease, herpes zoster), tumor, stroke, sarcoidosis, Guillain-Barré syndrome 3
• Do NOT order routine laboratory testing or imaging for typical presentations 1, 3

Red Flags Requiring Imaging (MRI with and without contrast)

• Recurrent paralysis on same side 1
• Isolated branch paralysis 1
• Other cranial nerve involvement 1, 3
• Bilateral facial weakness 3
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1

Electrodiagnostic Testing

• May offer to patients with complete facial paralysis (not incomplete) 1
• Most reliable when performed 3-14 days post-onset 1

• 10% nerve response amplitude compared to unaffected side indicates excellent prognosis 1

• <10% function carries up to 50% risk of incomplete recovery 1

Follow-Up and Reassessment

Mandatory Follow-Up Timeline

• Initial visit within 72 hours for treatment initiation and eye care education 1
• Early 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

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings (suggests stroke, tumor, or CNS pathology) 1, 3
• Development of ocular symptoms (requires urgent ophthalmology referral) 1
• Progressive weakness beyond 3 weeks 1

Specialist Referral Indications

• Incomplete facial recovery at 3 months—refer to facial nerve specialist or facial plastic surgeon for reconstructive options 1
• Persistent eye closure problems—refer to ophthalmology 1
• Consider tarsorrhaphy (partial eyelid closure) or eyelid weight implantation for severe persistent lagophthalmos 1

Prognosis

Expected Recovery Rates

• Patients with incomplete paralysis: up to 94% complete recovery 1, 2
• Patients with complete paralysis: approximately 70% complete recovery within 6 months 1
• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Therapies NOT Recommended

• Physical therapy: no proven benefit over spontaneous recovery 1, 3
• Acupuncture: poor quality evidence, indeterminate benefit-harm ratio 1, 3
• Surgical decompression: rarely indicated except in specialized centers for specific cases 1
• Antiviral monotherapy: completely ineffective, never prescribe alone 1, 2

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates effectiveness 1
• Prescribing antivirals alone without corticosteroids (completely ineffective) 1, 2
• Inadequate eye protection leading to permanent corneal damage 1
• Failing to refer at 3 months with incomplete recovery, delaying reconstructive options 1
• Missing red flags suggesting alternative diagnoses (bilateral weakness, other cranial nerve involvement, progressive symptoms) 1, 3
• Overlooking psychological impact in patients with persistent facial asymmetry 1