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

Initial Treatment for Bell's Palsy

Prescribe oral corticosteroids within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy, using either prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper. 1

Primary Treatment Algorithm

Corticosteroid Therapy (First-Line, Mandatory)

• Initiate treatment within 72 hours of symptom onset for maximum effectiveness 1, 2
• Dosing options:
  • Prednisolone 50 mg orally once daily for 10 days 1, 2
  • Prednisone 60 mg orally once daily for 5 days, then taper by 10 mg daily over next 5 days 1, 2
• Evidence supporting steroids is robust: 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 1, 3
• The number needed to treat is only 6 patients to achieve one additional complete recovery 3

Antiviral Therapy (Optional Add-On Only)

• Never prescribe antivirals alone - they are completely ineffective as monotherapy 1, 4, 5
• May offer combination therapy with oral antivirals PLUS corticosteroids within 72 hours, though benefit is minimal 1, 4
• If using combination therapy: valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days 1, 4
• The BELLS trial showed no significant benefit from aciclovir alone or in combination with steroids 3
• Some evidence suggests combination therapy may reduce synkinesis rates, but this remains uncertain 2, 4

Mandatory Eye Protection (Critical for All Patients)

Immediate Implementation Required

• Assess eye closure ability at initial presentation - impaired closure requires aggressive protection to prevent corneal damage 1, 2
• Daytime protection:
  • Lubricating ophthalmic drops (hydroxypropyl methylcellulose preferred) every 1-2 hours while awake 1
  • Sunglasses outdoors for wind and particle protection 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 Triggers

• Complete inability to close the eye 1
• Signs of corneal exposure or damage (pain, redness, vision changes, discharge) 1
• Development of any ocular symptoms at any point during disease course 1, 6

Diagnostic Considerations Before Treatment

Confirm Bell's Palsy Diagnosis

• Acute unilateral facial weakness involving the forehead (distinguishes from central causes) 1, 4
• Onset within 72 hours 1
• No other identifiable cause on history and physical examination 1

Red Flags Requiring Imaging and Specialist Referral

• Do NOT treat as simple Bell's palsy if any of these present:
  • Recurrent paralysis on the same side (suggests tumor, sarcoidosis, Lyme disease) 1, 6
  • Bilateral facial weakness 1, 6
  • Isolated branch paralysis 1
  • Other cranial nerve involvement 1
  • Progressive weakness beyond 3 weeks 1
  • Temporal bone trauma or surgical injury 1

Testing NOT Recommended

• Routine laboratory testing is NOT indicated 1
• Diagnostic imaging is NOT indicated for typical presentations 1
• MRI with and without contrast reserved only for atypical features or no recovery after 3 months 1

Special Populations

Children

• Better prognosis than adults with up to 90% complete recovery rates 4
• Evidence for corticosteroid benefit in children is inconclusive 1
• Consider oral corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis with substantial caregiver participation in shared decision-making 1
• Most children recover completely without treatment 1

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1
• Up to 90% complete recovery rate 4
• Eye protection measures are essential and safe in pregnancy 1

Follow-Up Schedule

Mandatory Reassessment Points

• Early follow-up at 1-2 weeks: Monitor recovery progress, reinforce eye protection, identify complications 1
• 3-month assessment: Mandatory reassessment or specialist referral for incomplete facial recovery 1, 2, 6
• Urgent evaluation at any time for:
  • New or worsening neurologic findings 1, 2, 6
  • Development of ocular symptoms 1, 2, 6

Expected Recovery Timeline

• Most patients begin showing recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• Patients with incomplete paralysis at presentation have excellent prognosis (up to 94% recovery) 1, 6
• Patients with complete paralysis have approximately 70% complete recovery rate within 6 months 1, 6
• 30% may experience permanent facial weakness with muscle contractures 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours significantly reduces effectiveness 1, 2
• Prescribing antivirals alone is completely ineffective and delays appropriate treatment 1, 4, 5
• Using standard methylprednisolone dose packs provides only 105 mg prednisone equivalent versus 540 mg needed, representing significant underdosing 1
• Inadequate eye protection counseling can lead to permanent corneal damage 1, 2
• Failing to recognize atypical features delays diagnosis of serious underlying conditions like tumor or stroke 1, 6
• Missing the 3-month reassessment delays access to reconstructive options and specialist care 1, 2