Initial Treatment for Bell's Palsy in Female Patients
Prescribe oral corticosteroids immediately within 72 hours of symptom onset—prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper—combined with aggressive eye protection measures. 1, 2
Primary Treatment: Corticosteroids (Must Initiate Within 72 Hours)
Corticosteroids are the only proven effective treatment and must be started within 72 hours of symptom onset. 1, 2 Treatment beyond this window provides no benefit. 2
Evidence-Based Regimens (Choose One):
- Prednisolone 50 mg orally daily for 10 days 1, 2
- Prednisone 60 mg orally daily for 5 days, then 5-day taper 1, 2
Strength of Evidence:
- 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1, 3
- 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1, 3
Antiviral Therapy: Optional Addition with Minimal Benefit
Never prescribe antiviral monotherapy—it is completely ineffective. 1, 2, 4
You may offer antivirals in combination with corticosteroids within 72 hours, though the added benefit is minimal: 1, 2
- Valacyclovir 1 g orally three times daily for 7 days 4
- Acyclovir 400 mg orally five times daily for 10 days 1, 4
The combination may reduce synkinesis rates (96.5% complete recovery versus 89.7% with steroids alone), but corticosteroids remain the cornerstone of treatment. 1, 4
Eye Protection: Mandatory for All Patients with Impaired Eye Closure
Implement aggressive eye protection immediately to prevent permanent corneal damage. 1, 2
Daytime Protection:
- Lubricating eye drops every 1-2 hours while awake 1, 2
- Sunglasses outdoors to protect against wind and foreign particles 1, 2
Nighttime Protection:
- Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
- Moisture chambers using polyethylene covers for severe cases 1
Urgent Ophthalmology Referral If:
- Complete inability to close the eye 1
- Signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1
Special Population Considerations
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
Children:
- Better prognosis with up to 90% complete recovery rates 4
- Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 1, 2
- Prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper 1
Follow-Up and Reassessment Triggers
Mandatory 3-Month Reassessment:
Urgent Reassessment Required At Any Time For:
- New or worsening neurologic findings 1, 2
- Development of ocular symptoms 1, 2
- Progressive weakness beyond 3 weeks 1
- Bilateral facial weakness, isolated branch paralysis, or other cranial nerve involvement 1, 2
Prognosis to Discuss with Patient
- Incomplete paralysis: up to 94% complete recovery 1, 4
- Complete paralysis: approximately 70% complete recovery within 6 months 1, 4
- Most patients begin showing recovery within 2-3 weeks 1
- 30% may experience permanent facial weakness with muscle contractures 1
Critical Pitfalls to Avoid
- Delaying corticosteroids beyond 72 hours eliminates treatment effectiveness 1, 2
- Using antiviral monotherapy is completely ineffective and delays appropriate treatment 1, 2, 4
- Inadequate eye protection can cause permanent corneal damage 1, 2
- Ordering routine labs or imaging for typical presentations is unnecessary and increases costs without benefit 1, 2
- Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management 1, 2