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

Treatment of Bell's Palsy

Primary Treatment: Oral Corticosteroids

Start 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 complete recovery rates. 1, 2

Recommended Corticosteroid Regimens

Choose one of these evidence-based options:

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

Evidence Supporting Corticosteroids

The evidence is compelling:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 1, 3
• 94.4% complete recovery at 9 months with prednisolone versus 81.6% with placebo 1, 3
• Treatment within 48 hours yields the highest recovery rates, with 66-76% complete recovery compared to 51-58% without treatment 4
• No benefit exists beyond 72 hours of symptom onset 1, 2

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Antiviral Therapy: Limited Role

Never prescribe antiviral therapy alone—it is completely ineffective as monotherapy. 1, 2, 3

Optional Combination Therapy

You may offer antiviral therapy in addition to corticosteroids within 72 hours, though the added benefit is minimal:

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

The evidence shows:

• Acyclovir alone provides no benefit (71.2% recovery versus 75.7% without acyclovir, p=0.50) 3
• Combination therapy may slightly reduce synkinesis rates but offers minimal additional recovery benefit 6, 5
• One older study suggested benefit from combination therapy (87.5% complete recovery versus 68% with no treatment), but this compared combination therapy to no treatment at all, not to steroids alone 7

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Eye Protection: Mandatory for Impaired Eye Closure

Implement aggressive eye protection immediately for all patients with incomplete eye closure to prevent permanent corneal damage. 1, 2

Specific Eye Protection Measures

Apply these interventions in combination:

During waking hours:

• Lubricating eye drops every 1-2 hours 1, 2
• Sunglasses outdoors for protection against wind and particles 1, 2

At bedtime:

• Ophthalmic ointment for sustained moisture retention 1, 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent ophthalmology referral if:

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

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Follow-Up and Reassessment

Mandatory 3-Month Reassessment

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months after symptom onset. 1, 2

At this point, patients may benefit from:

• Evaluation for reconstructive procedures (eyelid weights, brow lifts, facial slings, nerve transfers) 1
• Continued ophthalmology management for persistent lagophthalmos 1
• Psychological support for quality of life issues 1

Urgent Reassessment Triggers (At Any Time)

Refer immediately if:

• New or worsening neurologic findings (suggests alternative diagnosis like stroke, tumor, or CNS pathology) 1, 2
• Development of ocular symptoms (requires urgent ophthalmology evaluation) 1, 2
• Progressive weakness beyond 3 weeks (red flag for alternative diagnosis) 1

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Special Populations

Children

• Children have better prognosis than adults with higher spontaneous recovery rates (up to 90%) 1, 5
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers 1, 2
• Never delay treatment beyond 72 hours 1

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
• Combination therapy with antivirals may be considered on an individualized basis 1

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Prognosis and Natural History

Understanding recovery patterns helps set realistic patient expectations:

For incomplete paralysis:

• Excellent prognosis with up to 94% complete recovery 1, 5
• Faster and more complete recovery expected 1

For complete paralysis:

• Approximately 70% complete recovery within 6 months 1
• 30% may experience permanent facial weakness with muscle contractures 1

Recovery timeline:

• Most patients begin showing recovery within 2-3 weeks 1, 2
• Complete recovery typically occurs within 3-4 months 1

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Common Pitfalls to Avoid

Delaying treatment beyond 72 hours: The treatment window is critical—effectiveness drops dramatically after 72 hours. 1, 2

Using antiviral monotherapy: This is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 3

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 incomplete recovery. 1

Missing atypical features: Bilateral weakness, forehead sparing (suggests stroke), isolated branch paralysis, other cranial nerve involvement, or recurrent paralysis all suggest alternative diagnoses requiring imaging. 1, 2

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

Using standard methylprednisolone dose packs: These provide only 105 mg prednisone equivalent versus 540 mg over 14 days with proper dosing, representing significant underdosing. 1