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—this is the only proven effective treatment that significantly improves facial nerve recovery. 1

Immediate First-Line Treatment

Oral corticosteroids must be initiated within 72 hours of symptom onset for patients 16 years and older. 1 The evidence is compelling: 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

Recommended Corticosteroid Regimens

Choose one of these evidence-based regimens:

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

For patients significantly below or above average weight, consider weight-based dosing of 1 mg/kg/day (maximum 60 mg/day). 1

Critical Timing Consideration

Do not initiate corticosteroids beyond 72 hours of symptom onset—there is no evidence of benefit after this window. 1 Delaying treatment beyond 72 hours reduces effectiveness. 1

Antiviral Therapy: Limited Role

Never prescribe antiviral therapy alone—it is completely ineffective as monotherapy. 1, 2

You may offer combination therapy (oral antiviral plus corticosteroids) within 72 hours, but understand the added benefit is minimal. 1 Some evidence shows 96.5% complete recovery with combination therapy versus 89.7% with steroids alone, but this small benefit must be weighed against minimal risks. 1

If choosing combination therapy:

• Valacyclovir 1 g three times daily for 7 days 2, OR
• Acyclovir 400 mg five times daily for 10 days 1, 2

Eye Protection: Mandatory and Critical

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

Structured Eye Protection Protocol

Daytime protection:

• Lubricating ophthalmic drops every 1-2 hours while awake 1
• Sunglasses outdoors to protect against wind and foreign particles 1

Nighttime protection:

• Ophthalmic ointment at bedtime for sustained moisture retention 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

Urgent ophthalmology referral required for:

• Severe impairment with complete inability to close the eye 1
• Eye pain, vision changes, redness, discharge, or foreign body sensation 1
• Any signs of corneal exposure or damage 1

Common Eye Protection Pitfall

Improper eye taping technique can cause corneal abrasion—patients must receive careful instruction. 1 Relying solely on drops without nighttime protection can lead to exposure keratitis. 1

Treatments NOT Recommended

Do not order routine laboratory testing or diagnostic imaging for typical Bell's palsy presentations. 1 These tests do not aid diagnosis and delay treatment. 1

Do not prescribe physical therapy—there is no proven benefit over spontaneous recovery. 1

Do not recommend acupuncture—poor quality evidence shows an indeterminate benefit-harm ratio. 1

Do not perform surgical decompression except in rare specialized cases. 1

Special Populations

Children

Children have better prognosis with higher spontaneous recovery rates (up to 90%). 2 The benefit of corticosteroid treatment in children is inconclusive. 1 Consider oral corticosteroids on an individualized basis with substantial caregiver participation in shared decision-making, particularly for severe or complete paralysis. 1 Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper if treatment is chosen. 1

Pregnant Women

Treat pregnant women with oral corticosteroids within 72 hours using the same regimens as non-pregnant adults, with careful individualized assessment of benefits and risks. 1 Eye protection measures are essential and safe in pregnancy. 1

Mandatory Follow-Up and Referral Triggers

Reassess or refer to a facial nerve specialist at 3 months if facial recovery is incomplete. 1

Immediate reassessment or referral required at any time for:

• New or worsening neurologic findings (suggests stroke, tumor, or CNS pathology) 1, 3
• Development of ocular symptoms 1
• Progressive weakness beyond 3 weeks (red flag for alternative diagnosis) 3

Early follow-up at 1-2 weeks is valuable for monitoring recovery progress, reinforcing eye protection, and identifying complications. 1

Atypical Features Requiring Imaging

Order MRI with and without contrast if any of these features are present:

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

These features suggest tumor, stroke, Lyme disease, sarcoidosis, or other alternative diagnoses requiring different management. 3

Prognosis and Natural History

Approximately 70% of patients with complete paralysis recover completely within 6 months, while those with incomplete paralysis have recovery rates up to 94%. 1, 2 Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 1

However, 30% may experience permanent facial weakness with muscle contractures, requiring long-term management including potential reconstructive surgery, ophthalmology follow-up for persistent lagophthalmos, and psychological support for quality of life issues. 1