Step-by-Step Treatment for Bell's Palsy in a 50-Year-Old Female
Initiate oral corticosteroids immediately within 72 hours of symptom onset with 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 increases facial nerve recovery from 63.6% to 83% at 3 months. 1
Step 1: Confirm Diagnosis (Within 72 Hours of Onset)
Clinical Features Required:
- Acute unilateral facial weakness involving the forehead (cannot raise eyebrow on affected side) 1
- Onset within 72 hours 1
- No other neurologic deficits (no limb weakness, speech problems, or other cranial nerve involvement) 1, 2
- May have ipsilateral ear/facial pain, taste disturbance, hyperacusis, or dry eye 2
Red Flags Requiring Imaging (NOT Bell's Palsy):
- Forehead sparing (suggests stroke) 2
- Bilateral facial weakness 2
- Progressive weakness beyond 3 weeks 1
- Other cranial nerve involvement 1
- Isolated branch paralysis 1
Do NOT order routine labs or imaging for typical presentations 1, 3
Step 2: Initiate Corticosteroid Therapy (MUST Start Within 72 Hours)
Primary Regimen (Choose One):
Prednisolone 50 mg orally once daily for 10 days 1, 3
OR
Prednisone 60 mg orally once daily for 5 days, then taper over 5 days (e.g., 50 mg day 6,40 mg day 7,30 mg day 8,20 mg day 9,10 mg day 10) 1, 3
Evidence: Corticosteroids increase complete recovery from 63.6% (placebo) to 83% at 3 months and from 81.6% to 94.4% at 9 months 1
Critical Timing: Treatment beyond 72 hours has no proven benefit 1, 3
Step 3: Consider Adding Antiviral Therapy (Optional, Small Benefit)
If choosing combination therapy, add ONE of the following:
Valacyclovir 1000 mg orally three times daily for 7 days 4
OR
Evidence: Combination therapy may increase complete recovery from 89.7% to 96.5%, but the added benefit is minimal 1, 3
NEVER prescribe antivirals alone—they are completely ineffective as monotherapy 1, 3, 4
Step 4: Implement Eye Protection (Start Immediately)
For patients with incomplete eye closure:
Daytime Protection:
- Lubricating eye drops (preservative-free artificial tears) every 1-2 hours while awake 1
- Sunglasses outdoors to protect against wind and particles 1
Nighttime Protection:
- Ophthalmic ointment (e.g., erythromycin or lacri-lube) applied at bedtime 1
- Eye taping or patching with proper technique instruction 1
- Consider moisture chamber (polyethylene cover) for severe cases 1
Urgent ophthalmology referral if:
- Complete inability to close eye 1
- Eye pain, vision changes, redness, or discharge 1
- Signs of corneal exposure or damage 1
Step 5: Patient Education and Follow-Up Schedule
Initial Visit (Day 0-3):
- Initiate treatment and eye protection education 1
- Explain 70% complete recovery rate within 6 months for complete paralysis, 94% for incomplete paralysis 1
Early Follow-Up (1-2 Weeks):
- Assess recovery trajectory and reinforce eye protection 1
- Monitor for complications or new neurologic findings 1
Mandatory Reassessment (3 Months):
- Refer to facial nerve specialist if incomplete recovery at 3 months 1, 3
- Urgent referral at ANY time for new/worsening neurologic findings or ocular symptoms 1, 3
Step 6: Therapies to AVOID
Do NOT recommend:
- Physical therapy (no proven benefit over spontaneous recovery) 1, 4
- Acupuncture (poor quality evidence, indeterminate benefit-harm ratio) 1
- Antiviral monotherapy (completely ineffective) 1, 3, 4
- Routine laboratory testing or imaging for typical presentations 1, 3
Common Pitfalls to Avoid
- Delaying corticosteroids beyond 72 hours eliminates treatment benefit 1, 3
- Using standard methylprednisolone dose pack provides only 105 mg prednisone equivalent vs. required 540 mg over 14 days—this is significant underdosing 1
- Prescribing antivirals alone is ineffective and delays appropriate corticosteroid treatment 1, 3
- Inadequate eye protection monitoring can lead to permanent corneal damage 1
- Failing to refer at 3 months delays access to reconstructive options for the 30% who develop permanent weakness 1