What is the recommended treatment for a patient with facial nerve palsy, likely Bell's palsy, with a potential viral cause, and no known history of herpes zoster?

Treatment of Facial Nerve Palsy (Bell's Palsy) with Acyclovir

Acyclovir (or valacyclovir) should NOT be prescribed as monotherapy for Bell's palsy, but may be offered in combination with oral corticosteroids within 72 hours of symptom onset, though the added benefit is minimal and corticosteroids alone remain the proven effective treatment. 1, 2

Primary Treatment: Corticosteroids Are Essential

• Oral corticosteroids must be prescribed within 72 hours of symptom onset for all patients 16 years and older with Bell's palsy 1, 2
• The recommended regimen is prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Evidence demonstrates 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo 1
• No benefit exists when treatment is initiated beyond 72 hours 2

Antiviral Therapy: Limited and Controversial Role

Strong Evidence Against Monotherapy

• Antiviral monotherapy is completely ineffective and strongly contraindicated 1, 2
• The highest quality recent trial (2008, Lancet Neurology) with 829 patients showed valacyclovir provided no benefit: time to recovery was identical between patients receiving valacyclovir versus those who did not (hazard ratio 1.01,95% CI 0.85-1.19; p=0.90) 3

Combination Therapy: Optional with Minimal Benefit

• Clinicians may offer oral antiviral therapy (acyclovir or valacyclovir) in addition to oral steroids within 72 hours of symptom onset 4, 1
• Some older, smaller studies suggest marginally higher complete recovery rates with combination therapy (96.5%) compared to steroids alone (89.7%), but this benefit is small 1
• The American Academy of Otolaryngology-Head and Neck Surgery classifies combination therapy as an "option" rather than a recommendation, acknowledging minimal benefit with minimal risk 1

Dosing If Combination Therapy Is Chosen

• Valacyclovir: 1000 mg orally three times daily for 7 days 3
• Acyclovir: 400 mg orally five times daily for 10 days (alternative due to lower bioavailability requiring more frequent dosing) 1

Critical Eye Protection Measures (Mandatory)

All patients with impaired eye closure require aggressive eye protection to prevent permanent corneal damage 1, 2:

• Lubricating ophthalmic 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 for severe impairment with complete inability to close the eye 1

Follow-Up and Reassessment Algorithm

Mandatory 3-Month Reassessment

• All patients with incomplete facial recovery at 3 months must be referred to a facial nerve specialist for evaluation of reconstructive options 1, 2

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings require immediate specialist referral to exclude stroke, tumor, or CNS pathology 1, 2
• Development of ocular symptoms necessitates urgent ophthalmology referral 1, 2
• Progressive weakness beyond 3 weeks is a red flag requiring immediate reassessment 1

Common Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours dramatically reduces effectiveness 2
• Using antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment 1, 2
• 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 for the 30% of patients who may experience permanent facial weakness 1
• Missing atypical features (bilateral weakness, forehead sparing, isolated branch paralysis, other cranial nerve involvement) that suggest alternative diagnoses requiring different management 1, 2

Special Populations

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 5
• Combination therapy with antivirals may be considered on an individualized basis 5
• Eye protection measures are essential and safe in pregnancy 5

Children

• Children have better prognosis with higher rates of spontaneous recovery than adults 1
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, though pediatric evidence is less conclusive than adult data 1, 2

Prognosis Context

• Patients with incomplete facial weakness have excellent prognosis with recovery rates up to 94% 1
• Patients with complete paralysis have approximately 70% complete recovery within 6 months 1
• Most patients begin showing recovery within 2-3 weeks of symptom onset 1