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 and implement aggressive eye protection measures immediately. 1, 2, 3

Corticosteroid Therapy (First-Line Treatment)

Initiate corticosteroids within 72 hours—this is the critical treatment window with no benefit beyond this timeframe. 1, 2, 3

Recommended Regimens (Choose One):

• Prednisolone 50 mg daily for 10 days 1, 2, 3
• Prednisone 60 mg daily for 5 days, followed by a 5-day taper 1, 2, 3

Evidence Supporting Corticosteroids:

• 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo 2, 4, 5
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 2, 4, 5
• Number needed to treat (NNT) = 6 at 3 months 5

Critical Pitfall: Delaying treatment beyond 72 hours dramatically reduces effectiveness—treatment must be initiated immediately upon diagnosis. 2, 3

Antiviral Therapy (Limited Role)

Do NOT prescribe antiviral monotherapy—it is completely ineffective and strongly contraindicated. 1, 2, 3, 4, 5

Optional Combination Therapy:

You may offer antivirals in addition to corticosteroids within 72 hours, though the added benefit is minimal: 1, 2, 3

• Valacyclovir 1 g three times daily for 7 days, OR 6
• Acyclovir 400 mg five times daily for 10 days 2, 6

Evidence: Combination therapy shows only marginal improvement (96.5% recovery versus 89.7% with steroids alone), and the benefit-harm ratio is essentially neutral. 1, 2 The 2007 landmark trial found no benefit of acyclovir alone or in combination with prednisolone. 4

Mandatory Eye Protection

Implement eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage. 1, 2, 3

Specific Eye Protection Protocol:

• Lubricating eye drops every 1-2 hours while awake 2, 3
• Ophthalmic ointment at bedtime for sustained moisture retention 2, 3
• Sunglasses outdoors to protect against wind and foreign particles 2, 3
• Eye taping or patching at night with careful instruction on proper technique to avoid corneal abrasion 2, 3
• Moisture chambers (polyethylene covers) for severe cases 2

Urgent ophthalmology referral is required for patients with complete inability to close the eye or signs of corneal exposure. 2

Diagnostic Assessment (Before Treatment)

History and Physical Examination:

Perform a focused assessment to exclude alternative causes: 1, 2, 3

• Assess forehead involvement—Bell's palsy affects the forehead; stroke spares it 2, 3
• Verify acute onset developing over 24-72 hours 1, 2
• Exclude trauma (temporal bone fracture, surgical injury) 2, 3
• Rule out infection, tumor, or stroke 2, 3

Red Flags Suggesting Alternative Diagnosis:

• Bilateral facial weakness 2
• Isolated branch paralysis 2
• Other cranial nerve involvement 1, 2
• Forehead sparing (suggests central lesion/stroke) 2, 3
• Progressive weakness beyond 3 weeks 2

Testing NOT Recommended:

• Do NOT order routine laboratory testing 1, 2, 3
• Do NOT order diagnostic imaging for typical presentations 1, 2, 3

Special Populations

Children (Under 16 Years):

• Children have better prognosis with up to 90% spontaneous recovery 6
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers 2, 3
• Evidence for steroid benefit in children is less conclusive than in adults 2

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 2, 3
• Eye protection measures are essential and safe in pregnancy 2

Follow-Up and Reassessment Triggers

Mandatory 3-Month Reassessment:

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

Urgent Reassessment Required for:

• New or worsening neurologic findings at any point 1, 2, 3
• Development of ocular symptoms at any point 1, 2, 3
• Progressive weakness beyond 3 weeks 2

Prognosis

Expected Recovery Rates:

• Incomplete paralysis at presentation: Up to 94% complete recovery 2, 7
• Complete paralysis: Approximately 70% complete recovery within 6 months 2, 7
• Most patients begin showing recovery within 2-3 weeks 2
• 30% may experience permanent facial weakness with muscle contractures 2

Common Pitfalls to Avoid

1. Delaying corticosteroids beyond 72 hours—effectiveness drops dramatically 2, 3
2. Prescribing antiviral monotherapy—completely ineffective and delays appropriate treatment 1, 2, 3
3. Inadequate eye protection—can lead to permanent corneal damage 2, 3
4. Ordering unnecessary labs or imaging for typical presentations—increases costs without benefit 1, 2, 3
5. Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) that suggest alternative diagnoses 2, 3
6. Failing to refer at 3 months for incomplete recovery—delays access to reconstructive options 2, 3