What treatment options are available for a patient experiencing a Bell's palsy flare-up while taking Zoloft (sertraline)?

Bell's Palsy and Zoloft (Sertraline)

There is no established causal relationship between sertraline (Zoloft) and Bell's palsy flare-ups or recurrence, and treatment should focus on standard Bell's palsy management with corticosteroids initiated within 72 hours if this represents a new episode. 1

Immediate Assessment and Treatment

If this is a new episode of Bell's palsy (not a true "flare-up" of previous Bell's palsy), prescribe oral corticosteroids immediately if the patient presents within 72 hours of symptom onset. 1, 2

• Use prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper 1, 2
• Treatment beyond 72 hours provides no benefit 1, 2
• Evidence shows 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1

Do not discontinue sertraline based solely on temporal association with Bell's palsy, as no evidence supports sertraline as a causative agent. The guidelines and literature do not identify SSRIs as risk factors or triggers for Bell's palsy. 1

Critical Distinction: New Episode vs. Worsening of Previous Bell's Palsy

If the patient is experiencing worsening symptoms or increased pain after completing initial Bell's palsy treatment, this requires immediate reassessment or specialist referral, as progressive weakness beyond the expected recovery timeline suggests an alternative diagnosis. 1

• Perform focused neurological examination for new cranial nerve involvement 1
• Look for signs of head and neck malignancy 1
• Order MRI with and without contrast if atypical features present 1

Mandatory Eye Protection

Implement aggressive eye protection immediately for any degree of impaired eye closure to prevent permanent corneal damage. 1, 2

Daytime measures:

• Lubricating eye drops every 1-2 hours while awake 1, 2
• Sunglasses outdoors to protect against wind and particles 1, 2

Nighttime measures:

• Ophthalmic ointment at bedtime for sustained moisture 1, 2
• Eye taping or patching with careful instruction on proper technique 1, 2

Antiviral Therapy Considerations

Do not prescribe antiviral monotherapy alone, as it is completely ineffective. 1, 2, 3

• Antiviral therapy (valacyclovir 1000 mg daily for 5 days) may be added to corticosteroids within 72 hours, but the added benefit is minimal 1, 4
• One study showed 96.5% recovery with combination therapy versus 89.7% with steroids alone, but this represents a modest benefit at best 4, 3

Red Flags Requiring Imaging or Specialist Referral

Order MRI with and without contrast if any of the following are present: 1, 2

• Recurrent paralysis on the same side 1
• Bilateral facial weakness 1, 2
• Isolated branch paralysis 1, 2
• Other cranial nerve involvement 1, 2
• Progressive weakness beyond 3 weeks 1
• No recovery after 3 months 1, 2

Follow-Up Timeline

• Early reassessment at 1-2 weeks to monitor recovery progress, reinforce eye protection, and identify complications 1, 2
• Mandatory reassessment or specialist referral at 3 months if facial recovery is incomplete, as approximately 30% of patients may have permanent facial weakness requiring long-term management 1, 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates corticosteroid effectiveness 1, 2
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate corticosteroid treatment 1, 2, 3
• Inadequate eye protection monitoring can lead to permanent corneal damage 1, 2
• Attributing Bell's palsy to sertraline without evidence may lead to inappropriate medication discontinuation that could worsen the patient's underlying psychiatric condition 1