What is the recommended treatment for a patient with Bell's palsy, considering their medical history and potential underlying conditions such as diabetes or hypertension?

Treatment for Bell's Palsy

Prescribe oral corticosteroids immediately—prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—within 72 hours of symptom onset for all patients 16 years and older, as this significantly improves complete recovery rates from 63.6% to 83% at 3 months. 1, 2

Immediate Treatment Protocol (Within 72 Hours)

Corticosteroid Therapy (First-Line, Mandatory)

• Start treatment immediately for patients presenting within 72 hours of unilateral facial weakness onset 1, 2
• Dosing options:
  • Prednisolone 50 mg orally daily for 10 days, OR 1, 2
  • Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over next 5 days 1, 2
• Evidence: Recovery rates at 9 months reach 94.4% with prednisolone versus 81.6% with placebo 1, 3
• Critical timing: No benefit exists beyond the 72-hour window 1, 2

Antiviral Therapy (Optional Add-On Only)

• Never prescribe antivirals alone—they are completely ineffective as monotherapy 1, 2, 3
• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids 1, 4
• Minimal added benefit: Combination therapy shows 96.5% complete recovery versus 89.7% with steroids alone 2
• The 2007 landmark trial showed no benefit of acyclovir alone (71.2% recovery) versus no acyclovir (75.7% recovery) at 3 months 3

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

Daytime Measures

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

Nighttime Measures

• Ophthalmic ointment at bedtime for sustained moisture retention 1, 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1, 2
• Consider moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Triggers

• Severe impairment with complete inability to close the eye 1
• Any signs of corneal exposure or damage (eye pain, vision changes, redness, discharge) 1
• Persistent lagophthalmos beyond 3 months may require tarsorrhaphy or eyelid weight implantation 1

Special Populations

Patients with Diabetes or Hypertension

• Treat identically to general population with standard corticosteroid regimens 1, 2
• Diabetes does not affect severity, recovery rate, or healing time of Bell's palsy 5
• Monitor blood glucose more frequently in diabetic patients on corticosteroids, but do not withhold treatment 5
• Hypertension is not a contraindication to short-term corticosteroid therapy 1

Children

• Better prognosis: Up to 90% spontaneous recovery rate, higher than adults 1, 4
• Consider corticosteroids (prednisolone 1 mg/kg/day, maximum 50-60 mg) for severe or complete paralysis after shared decision-making with caregivers 1, 2
• Evidence for steroid benefit in children is less conclusive than in adults 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 1, 2
• Recovery rates up to 90% in pregnancy 4
• Eye protection measures are essential and safe in pregnancy 1

Follow-Up Schedule

Early Reassessment (1-2 Weeks)

• Monitor recovery progress and reinforce eye protection 2
• Identify early complications or new neurologic findings 1, 2

Mandatory 3-Month Reassessment

• Refer to facial nerve specialist if facial recovery is incomplete at 3 months 1, 2
• Approximately 30% of patients may have permanent facial weakness requiring long-term management 1, 2

Immediate Referral Triggers (Any Time Point)

• New or worsening neurologic findings suggesting alternative diagnosis 1, 2
• Development of ocular symptoms (pain, vision changes, corneal damage) 1, 2
• Progressive weakness beyond 3 weeks 1

Diagnostic Testing (NOT Routinely Recommended)

Typical Presentation

• No laboratory testing or imaging required for diagnosis 1, 2, 6
• Diagnosis is clinical: acute onset (<72 hours) of unilateral facial weakness involving the forehead 1, 6, 4

Red Flags Requiring MRI with and without Contrast

• Bilateral facial weakness 1, 2, 6
• Isolated branch paralysis 1, 2
• Other cranial nerve involvement 1, 2, 6
• Recurrent paralysis on same side 1
• No recovery after 3 months 1, 2
• Progressive weakness beyond 3 weeks 1

Electrodiagnostic Testing

• May offer to patients with complete facial paralysis (not incomplete) 1
• Most reliable when performed 3-14 days post-onset 1

• 10% nerve response amplitude indicates excellent prognosis 1

Therapies NOT Recommended

• Physical therapy: No proven benefit over spontaneous recovery 1, 2, 4
• Acupuncture: Poor-quality evidence with indeterminate benefit-harm ratio 1, 2
• Surgical decompression: Rarely indicated except in specialized circumstances 1, 2
• Antiviral monotherapy: Completely ineffective and delays appropriate treatment 1, 2, 3

Critical Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment effectiveness 1, 2
• Prescribing antivirals alone is ineffective and delays proper corticosteroid therapy 1, 2, 3
• Inadequate eye protection can lead to permanent corneal damage, especially with severe lagophthalmos 1, 2
• Missing central causes: Forehead sparing indicates stroke, not Bell's palsy 6, 4
• Failing to refer at 3 months delays reconstructive options and psychological support 1, 2
• Ordering routine labs or imaging for typical presentations increases costs without benefit 1, 2
• Using standard methylprednisolone dose packs provides only 105 mg prednisone equivalent versus the required 540 mg over 14 days, representing significant underdosing 1