What is the recommended treatment for a patient with Bell's palsy, particularly within 72 hours of symptom onset and with a potential history of herpes simplex virus infection?

Bell's Palsy Treatment

Prescribe oral corticosteroids immediately—within 72 hours of symptom onset—using 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 Treatment Algorithm (Within 72 Hours)

First-Line Therapy: Corticosteroids Alone

• Start oral corticosteroids immediately for all patients ≥16 years old presenting within 72 hours of symptom onset 1
• Dosing options:
  • Prednisolone 50 mg daily for 10 days (preferred), OR 1
  • Prednisone 60 mg daily for 5 days, then 5-day taper 1
• Evidence supporting this: 83% recovery at 3 months with prednisolone vs 63.6% with placebo; 94.4% recovery at 9 months vs 81.6% with placebo 1

Optional Add-On: Combination Therapy

• Consider adding antiviral therapy to corticosteroids (not as monotherapy) within 72 hours if the patient has severe or complete paralysis 1
• Antiviral options:
  • Valacyclovir 1 g three times daily for 7 days, OR 2
  • Acyclovir 400 mg five times daily for 10 days 1, 2
• Benefit is modest: 96.5% complete recovery with combination therapy vs 89.7% with steroids alone 1
• Never prescribe antivirals alone—they are ineffective as monotherapy 1, 2

Critical Timing Consideration

• Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence of benefit after this window 1

Mandatory Eye Protection (All Patients with Incomplete Eye Closure)

Immediate Implementation

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Ophthalmic ointment at bedtime for sustained moisture 1
• Eye taping or patching at night with careful instruction to avoid corneal abrasion 1
• Sunglasses outdoors for protection against wind and particles 1
• Moisture chambers (polyethylene covers) for severe cases 1

Urgent Ophthalmology Referral Triggers

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, or discharge 1
• Signs of corneal exposure or damage 1

Diagnosis Confirmation (Before Treatment)

Required Clinical Features

• Rapid onset (<72 hours) of unilateral facial weakness involving the forehead 3, 1
• Complete hemifacial weakness including inability to raise eyebrow, close eye, or smile symmetrically 3
• No other neurologic abnormalities—Bell's palsy is a diagnosis of exclusion 3, 1

Red Flags Requiring Imaging (MRI with contrast)

• Bilateral facial weakness (suggests Guillain-Barré or sarcoidosis, not Bell's palsy) 3, 4
• Isolated branch paralysis (suggests tumor) 1
• Other cranial nerve involvement (suggests stroke or tumor) 3, 1
• Progressive weakness beyond 3 weeks (suggests alternative diagnosis) 1
• Recurrent paralysis on same side (suggests tumor) 1

Distinguishing from Stroke

• Stroke spares the forehead (central facial weakness) because of bilateral cortical innervation 3
• Bell's palsy affects the entire ipsilateral face including forehead 3
• Stroke typically presents with additional neurologic symptoms: dizziness, dysphagia, diplopia, limb weakness, or speech difficulties 3

Special Populations

Children

• Better prognosis with up to 90% complete spontaneous recovery 2
• Corticosteroid benefit is unproven in pediatric patients—no high-quality pediatric trials exist 1
• Consider treatment on individualized basis with substantial caregiver involvement in shared decision-making 1
• If treating: prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, then 5-day taper 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using the same regimen as non-pregnant adults 1
• Careful individualized assessment of benefits and risks is recommended 1
• Eye protection is essential and safe in pregnancy 1

Mandatory Follow-Up and Referral Triggers

At 3 Months

• Refer to facial nerve specialist if incomplete facial recovery at 3 months 1
• Approximately 30% of patients experience permanent facial weakness requiring reconstructive evaluation 1

At Any Time Point (Urgent)

• New or worsening neurologic findings at any point (suggests alternative diagnosis) 1
• Development of ocular symptoms at any point (risk of permanent corneal damage) 1

Therapies NOT Recommended

Strong Evidence Against

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

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates the proven benefit of corticosteroids 1
• Prescribing antivirals alone is ineffective and delays appropriate corticosteroid treatment 1
• Inadequate eye protection can lead to permanent corneal damage, particularly with complete lagophthalmos 1
• Failing to refer at 3 months delays access to reconstructive options for patients with incomplete recovery 1
• Missing red flags such as bilateral weakness, other cranial nerve involvement, or progressive symptoms that suggest alternative diagnoses requiring imaging 3, 1
• Underdosing corticosteroids—ensure adequate dosing with prednisolone 50 mg or prednisone 60 mg, not lower doses 1

Natural History and Prognosis

• 70-80% of patients recover spontaneously without treatment 5, 6
• Patients with incomplete paralysis have excellent prognosis with up to 94% recovery 1
• Most patients begin recovery within 2-3 weeks of symptom onset 1
• Complete recovery typically occurs within 3-4 months for most patients 1
• 30% may experience permanent weakness with muscle contractures requiring long-term management 1