What is the recommended treatment for an adult patient with no underlying medical conditions diagnosed with Bell’s palsy?

Treatment of Bell's Palsy in Adults

Prescribe oral corticosteroids within 72 hours of symptom onset—specifically prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—as this is the only proven effective treatment that significantly improves facial nerve recovery. 1

Immediate Management (Within 72 Hours)

Corticosteroid Therapy: The Cornerstone

• Start prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days with a 5-day taper 1
• 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
• Treatment beyond 72 hours has no proven benefit and should not be initiated 1

Antiviral Therapy: Optional Add-On Only

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 2
• May offer valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days in combination with corticosteroids 1, 2
• The added benefit is minimal (96.5% complete recovery with combination versus 89.7% with steroids alone), but risks are low 1
• This is an option, not a recommendation—corticosteroids remain the essential treatment 1

Eye Protection: Critical and Non-Negotiable

• Apply lubricating ophthalmic drops every 1-2 hours while awake 1
• Use ophthalmic ointment at bedtime for sustained moisture retention 1
• Tape or patch the eye at night with careful instruction to avoid corneal abrasion 1
• Prescribe sunglasses for outdoor use to protect against wind and particles 1
• Consider moisture chambers (polyethylene covers) for severe cases 1
• Refer urgently to ophthalmology if complete inability to close the eye or any signs of corneal exposure develop 1

Diagnosis Confirmation

Clinical Features Required

• Acute onset of unilateral facial weakness developing over less than 72 hours 1, 2
• Forehead involvement (inability to wrinkle forehead or raise eyebrow on affected side) distinguishes this from stroke 3
• May have ipsilateral ear pain, taste disturbance, hyperacusis, or dry eye 1, 4

Exclude Alternative Diagnoses

• Document function of all cranial nerves—any additional cranial nerve involvement excludes Bell's palsy 4, 3
• Check for limb weakness, speech difficulties, or altered consciousness—their presence indicates stroke 3
• Assess for bilateral facial weakness—this is extremely rare in Bell's palsy and suggests Guillain-Barré syndrome, Lyme disease, or sarcoidosis 4, 3

No Routine Testing Needed

• Do not order laboratory tests or imaging for typical presentations 1, 4
• MRI with and without contrast is reserved for atypical features: recurrent paralysis on same side, isolated branch paralysis, other cranial nerve involvement, or no recovery after 3 months 1, 4

Therapies to Avoid

Do not recommend physical therapy, acupuncture, or surgical decompression—these have no proven benefit over spontaneous recovery. 1, 5

Follow-Up Algorithm

Early Follow-Up (1-2 Weeks)

• Assess recovery trajectory and reinforce eye protection 1
• Monitor for complications or new neurologic findings 1

Mandatory Reassessment Triggers

• Refer immediately if new or worsening neurologic findings develop at any point 1
• Refer immediately if ocular symptoms develop at any point 1
• Refer to facial nerve specialist if incomplete recovery at 3 months 1
• Progressive weakness beyond 3 weeks is a red flag requiring immediate reassessment 1

Long-Term Considerations

• Approximately 70% of patients with complete paralysis recover fully within 6 months 1, 6
• Patients with incomplete paralysis have up to 94% recovery rates 1
• 30% may experience permanent facial weakness requiring reconstructive options 1

Common Pitfalls

• Delaying corticosteroids beyond 72 hours eliminates their effectiveness 1
• Prescribing antivirals alone is completely ineffective and delays appropriate treatment 1, 2
• Inadequate eye protection can cause permanent corneal damage 1
• Missing forehead involvement leads to misdiagnosis of stroke as Bell's palsy 3
• Failing to refer at 3 months delays access to reconstructive surgery and psychological support 1