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

Treatment of Bell's Palsy

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 facial nerve recovery. 1, 2

Corticosteroid Regimen (First-Line Treatment)

Use one of these evidence-based regimens:

• Prednisolone 50 mg daily for 10 days, OR 1, 2
• Prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2

Critical timing: Treatment must be initiated within 72 hours of symptom onset—there is no benefit beyond this window. 1, 2 Delaying treatment beyond 72 hours dramatically reduces effectiveness. 2

Evidence supporting corticosteroids:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 3, 4
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 3, 4
• Number needed to treat is 6 at 3 months and 8 at 9 months 3

Antiviral Therapy (Limited Role)

Do NOT prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 3, 4

Optional combination therapy: You may offer antivirals in addition to corticosteroids within 72 hours, though the added benefit is minimal. 1, 2, 5 If choosing combination therapy:

• Valacyclovir 1 g three times daily for 7 days, OR 5
• Acyclovir 400 mg five times daily for 10 days 1, 5

The combination may reduce synkinesis rates (misdirected nerve regrowth causing involuntary facial muscle co-contraction), but corticosteroids remain the cornerstone of treatment. 5

Eye Protection (Mandatory for All Patients with Impaired Eye Closure)

Implement these measures immediately to prevent permanent corneal damage:

• Lubricating eye drops every 1-2 hours while awake 1, 2
• Ophthalmic ointment at bedtime for sustained 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 1

Urgent ophthalmology referral required for:

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

Follow-Up and Reassessment

Mandatory reassessment or specialist referral at 3 months if facial recovery is incomplete. 1, 2

Urgent reassessment required at any time for:

• New or worsening neurologic findings (suggests alternative diagnosis like stroke, tumor, or CNS pathology) 1, 2
• Development of ocular symptoms 1, 2
• Progressive weakness beyond 3 weeks (red flag for alternative diagnosis) 1
• Bilateral facial weakness, isolated branch paralysis, or other cranial nerve involvement 1, 2

Early follow-up at 1-2 weeks to monitor recovery progress, reinforce eye protection, and identify early complications. 1

Special Populations

Children:

• Have excellent prognosis with spontaneous recovery rates up to 90% 6, 5
• Corticosteroid benefit is inconclusive in pediatrics (unlike strong adult evidence) 1, 6
• May consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 6
• Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treating 1

Pregnant women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2
• Recovery rates up to 90% 5
• Eye protection measures are essential and safe in pregnancy 1

Diagnostic Assessment (Before Treatment)

Confirm Bell's palsy by excluding alternative causes through focused history and examination:

• Verify forehead involvement (Bell's palsy affects forehead; stroke spares it) 2
• Rule out trauma (temporal bone fracture, surgical injury) 1, 2
• Exclude infection, tumor, or stroke 2
• Confirm acute onset over 24-72 hours 1, 2

Do NOT order routine laboratory testing or imaging for typical presentations—this increases costs without benefit. 1, 2 MRI with and without contrast is reserved for atypical presentations or no recovery after 3 months. 1

Therapies NOT Recommended

Physical therapy: No recommendation can be made due to limited evidence (only case series available) and equilibrium of benefit versus harm. 1, 6, 7 Most patients recover spontaneously without additional interventions. 6

Acupuncture: No recommendation can be made due to poor-quality trials and indeterminate benefit-harm ratio. 1, 7

Surgical decompression: Rarely indicated except in specialized centers for specific cases. 1

Prognosis

Patients with incomplete facial weakness: Up to 94% complete recovery 1, 5

Patients with complete paralysis: Approximately 70% complete recovery within 6 months 1

Recovery timeline: Most patients begin showing improvement within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 1

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

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours reduces effectiveness dramatically 2
• Using antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 3, 4
• Inadequate eye protection can lead to permanent corneal damage 1, 2
• Failing to refer at 3 months delays access to reconstructive options for incomplete recovery 1, 2
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2
• Ordering routine labs or imaging for typical presentations is unnecessary and costly 1, 2