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

Bell's Palsy Treatment

Immediate First-Line Treatment

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 complete recovery rates from 63.6% to 83% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2

Corticosteroid Regimen (Choose One)

• Prednisolone 50 mg orally daily for 10 days 1, 3
• Prednisone 60 mg orally daily for 5 days, followed by a 5-day taper 1, 3

The number needed to treat is 6 patients to achieve one additional complete recovery at 3 months 4. Treatment beyond 72 hours has no proven benefit and should not be initiated 5, 3.

Antiviral Therapy: Limited Role

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate treatment. 1, 3, 2

• Antivirals (valacyclovir 1g three times daily for 7 days OR acyclovir 400mg five times daily for 10 days) may be offered as an addition to corticosteroids within 72 hours, though the added benefit is minimal 1, 6
• The evidence shows no significant improvement with acyclovir alone (71.2% recovery) compared to no acyclovir (75.7% recovery) 2, 4

Mandatory Eye Protection

Implement aggressive eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1, 3

Eye Protection Protocol

• Lubricating eye drops every 1-2 hours while awake 1, 3
• Ophthalmic ointment at bedtime for sustained moisture retention 1, 3
• Sunglasses outdoors to protect against wind and foreign particles 1, 3
• Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1, 3
• Moisture chambers using polyethylene covers for severe cases 1
• Urgent ophthalmology referral for complete inability to close the eye or signs of corneal exposure 1

Initial Diagnostic Assessment

Before diagnosing Bell's palsy, exclude alternative causes through focused history and examination 3:

• Assess forehead involvement—Bell's palsy affects the forehead, while stroke spares it 3
• Rule out trauma (temporal bone fracture, surgical injury) 3
• Exclude infection, tumor, or stroke 3
• Verify acute onset developing over 24-72 hours 3
• Do NOT order routine labs or imaging for typical presentations—they increase costs without benefit 1, 3

Red Flags Requiring Imaging (MRI with and without contrast)

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

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, 3

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings 1, 3
• Development of ocular symptoms 1, 3
• Progressive weakness beyond 3 weeks 1

Refer to a facial nerve specialist or facial plastic surgeon at 3 months if facial recovery is incomplete for evaluation of reconstructive options including static procedures (eyelid weights, brow lifts, facial slings) or dynamic procedures (nerve transfers). 1, 3

Special Populations

Children

• Children have better prognosis with up to 90% complete spontaneous recovery 6
• Evidence for corticosteroid benefit in children is inconclusive—a 2022 randomized controlled trial showed no significant improvement (49% recovery with prednisolone vs 57% with placebo at 1 month) 7
• Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper for severe or complete paralysis after shared decision-making with caregivers 1, 3

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 3
• Pregnant women have up to 90% complete recovery rates 6
• Eye protection measures are essential and safe in pregnancy 1

Prognosis

Expected Recovery Rates

• Incomplete paralysis at presentation: up to 94% complete recovery 1, 6
• Complete paralysis: approximately 70% complete recovery within 6 months 1, 6
• 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

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours dramatically reduces effectiveness 3
• Using antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment 1, 3, 2
• Inadequate eye protection can lead to permanent corneal damage 3
• 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, 3
• Ordering routine labs or imaging for typical presentations is unnecessary and increases costs 1, 3

Treatment After 72 Hours

If a patient presents at day 5 or beyond, do NOT initiate corticosteroids—focus entirely on eye protection and monitoring for recovery, as there is no evidence supporting steroid benefit after the 72-hour window. 5, 3 The vast majority of patients (70-94%) will recover spontaneously even without treatment. 5, 6