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

Initial Treatment of Bell's Palsy

Prescribe oral corticosteroids immediately if the patient presents within 72 hours of symptom onset, using either prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper, and implement aggressive eye protection measures for all patients with impaired eye closure. 1, 2

Critical Treatment Window

• Treatment must be initiated within 72 hours of symptom onset to achieve meaningful benefit—beyond this window, corticosteroids provide minimal to no improvement in recovery rates. 1, 3, 2

• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo when started within 72 hours, and 94.4% recovery at 9 months versus 81.6% with placebo. 1, 4

• If a patient presents at day 5 or later, do not initiate corticosteroids—focus exclusively on eye protection and supportive care instead. 3

Corticosteroid Regimen Selection

Choose one of these evidence-based regimens for patients ≥16 years presenting within 72 hours: 1, 2

• Prednisolone 50 mg orally daily for 10 days (preferred regimen), OR 1, 2

• Prednisone 60 mg orally daily for 5 days, then taper over 5 days 1, 2

• For significantly underweight or overweight patients, consider weight-based dosing at 1 mg/kg/day (maximum 60 mg/day) to ensure adequate dosing. 1

Antiviral Therapy: Limited Role

• Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 5, 4

• Combination therapy with antivirals plus corticosteroids may be offered as an option within 72 hours, though the added benefit is minimal. 1, 2, 5

• If choosing combination therapy, use valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days. 1, 5

• The evidence shows no significant additional benefit: 71.2% recovery with acyclovir versus 75.7% without acyclovir at 3 months. 4

Mandatory Eye Protection Protocol

All patients with impaired eye closure require immediate implementation of comprehensive eye protection to prevent corneal damage: 1, 2

• Lubricating eye drops every 1-2 hours while awake for daytime hydration 1, 2

• Ophthalmic ointment at bedtime for sustained overnight moisture retention 1, 2

• Sunglasses outdoors to protect against wind and foreign particles 1, 2

• Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 1, 2

• Moisture chambers using polyethylene covers for severe cases with complete inability to close the eye 1

• Urgent ophthalmology referral for patients with severe impairment, complete inability to close the eye, or any signs of corneal exposure or damage 1, 2

Special Population Considerations

Children (Age <16 years)

• Children have excellent prognosis with up to 90-94% spontaneous recovery rates without treatment. 1, 5

• The benefit of corticosteroids in children is unproven—a 2022 randomized controlled trial showed no significant improvement (49% recovery with prednisolone vs 57% with placebo at 1 month). 6

• Consider corticosteroids only for severe or complete paralysis after shared decision-making with caregivers, using prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper. 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1, 2

• Eye protection measures are essential and safe in pregnancy. 1

Follow-Up Schedule and Reassessment Triggers

Schedule initial follow-up at 1-2 weeks to assess recovery trajectory, reinforce eye protection, and identify early complications. 1

Mandatory reassessment or specialist referral is required for: 1, 2

• Incomplete facial recovery at 3 months after symptom onset 1, 2

• New or worsening neurologic findings at any point (suggests alternative diagnosis such as stroke, tumor, or CNS pathology) 1, 2

• Development of ocular symptoms at any point (requires urgent ophthalmology referral) 1, 2

• Progressive weakness beyond 3 weeks (red flag for alternative diagnosis) 1

Atypical Features Requiring Imaging

Do NOT order routine labs or imaging for typical Bell's palsy presentations. 1, 2

Order MRI with and without contrast if any of these atypical features are present: 1, 2

• Bilateral facial weakness 1, 2

• Isolated branch paralysis (not affecting entire side of face) 1, 2

• Other cranial nerve involvement 1, 2

• Recurrent paralysis on the same side 1

• No recovery after 3 months 1, 2

• Forehead sparing (suggests central/stroke etiology rather than Bell's palsy) 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours dramatically reduces effectiveness—there is no evidence supporting benefit after this window. 3, 2

• Prescribing antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 4

• Inadequate eye protection can lead to permanent corneal damage, particularly in patients with severe lagophthalmos. 1, 2

• Failing to refer at 3 months delays access to reconstructive options and psychological support for the 30% of patients with permanent facial weakness. 1, 2

• Using standard methylprednisolone dose packs provides only 105 mg prednisone equivalent versus the required 540 mg over 14 days, representing significant underdosing. 1

• Ordering routine labs or imaging for typical presentations increases costs without benefit. 1, 2

Prognosis and Natural History

• Patients with incomplete paralysis have excellent prognosis with up to 94% complete recovery. 1, 5

• Patients with complete paralysis have approximately 70% complete recovery within 6 months. 1, 3, 5

• Most patients begin showing signs of recovery within 2-3 weeks of symptom onset. 1, 3

• Approximately 30% may experience permanent facial weakness with muscle contractures requiring long-term management. 1