What is the initial treatment for a patient presenting with Bell's palsy?

Treatment of Bell's Palsy

Start oral corticosteroids immediately—within 72 hours of symptom onset—for all patients 16 years and older, combined with aggressive eye protection measures to prevent corneal damage. 1, 2, 3

Corticosteroid Therapy: The Cornerstone of Treatment

• Prednisolone 50 mg daily for 10 days OR prednisone 60 mg daily for 5 days followed by a 5-day taper are the evidence-based regimens that significantly improve complete recovery rates. 1, 2, 3

• Treatment effectiveness is time-critical: no benefit exists beyond 72 hours of symptom onset, so immediate initiation is essential. 1, 3

• The evidence is robust: 83% recovery at 3 months with prednisolone versus 63.6% with placebo, and 94.4% recovery at 9 months versus 81.6% with placebo. 2, 4, 5

• The number needed to treat is only 6 patients at 3 months and 8 patients at 9 months to achieve one additional complete recovery. 5

Antiviral Therapy: Minimal Role

• Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment. 1, 2, 3

• Antivirals (valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days) may be added to corticosteroids within 72 hours, but the added benefit is minimal. 1, 6

• High-quality trials show no significant benefit: 71.2% recovery with acyclovir versus 75.7% without acyclovir at 3 months. 4, 5

• The only potential small benefit is a possible reduction in synkinesis rates, though this remains uncertain. 6

Eye Protection: Mandatory and Non-Negotiable

All patients with impaired eye closure require immediate aggressive eye protection to prevent permanent corneal damage. 1, 2, 3

Daytime Protection:

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

Nighttime Protection:

• Ophthalmic ointment at bedtime for sustained moisture 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 Needed For:

• Complete inability to close the eye 1
• Eye pain, vision changes, redness, or discharge 1
• Signs of corneal exposure or damage 1

Initial Diagnostic Assessment

Bell's palsy is a diagnosis of exclusion—perform a focused examination to rule out alternative causes before initiating treatment. 1, 2, 3

Key Diagnostic Features to Confirm:

• Acute onset over 24-72 hours 2, 3
• Unilateral facial weakness involving the forehead (distinguishes from stroke, which spares the forehead) 2, 3, 6
• No other cranial nerve involvement 1, 3

Red Flags Requiring Imaging (MRI with and without contrast):

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

Do NOT Order:

• Routine laboratory testing for typical presentations 1, 2, 3
• Routine imaging for typical presentations 1, 2, 3

Follow-Up Schedule

Early Reassessment (1-2 weeks):

• Monitor recovery progress 1
• Reinforce eye protection measures 1
• Identify early complications 1

Mandatory Reassessment or Specialist Referral at 3 Months:

• All patients with incomplete facial recovery at 3 months require referral to a facial nerve specialist or facial plastic surgeon for evaluation of reconstructive options. 1, 2, 3
• Approximately 30% of patients may have permanent facial weakness requiring long-term management. 1

Urgent Reassessment Triggers (at any time):

• New or worsening neurologic findings 1, 2
• Development of ocular symptoms 1, 2

Special Populations

Children:

• Children have excellent prognosis with up to 90% spontaneous recovery. 1, 6
• Consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, as pediatric evidence is less conclusive than adult data. 1, 3
• Use prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by a 5-day taper if treatment is chosen. 2

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1, 3
• Eye protection measures are essential and safe in pregnancy. 1
• Pregnant women have up to 90% complete recovery rates. 6

Prognosis and Natural History

• Patients with incomplete paralysis at presentation have excellent prognosis with up to 94% complete recovery. 2, 6
• Patients with complete paralysis have approximately 70% complete recovery within 6 months. 1, 6
• Most patients begin showing recovery within 2-3 weeks. 1, 3
• Complete recovery typically occurs within 3-4 months for most patients. 1

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours eliminates the effectiveness of corticosteroid therapy. 1, 3
• Prescribing antiviral monotherapy is completely ineffective and delays appropriate treatment. 1, 2, 3
• Inadequate eye protection monitoring can lead to permanent corneal damage, particularly in patients with severe lagophthalmos. 1
• Failing to refer at 3 months delays access to reconstructive options and psychological support. 1
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve involvement) suggests alternative diagnoses requiring different management. 1, 3
• Ordering routine labs or imaging for typical presentations increases costs without benefit. 1, 3

Therapies NOT Recommended

Do not offer the following, as there is no proven benefit or insufficient evidence: 1, 2

• Physical therapy for incomplete paralysis 1, 7
• Acupuncture 1, 7
• Surgical decompression (except rare specialized cases) 1, 7
• Electrodiagnostic testing for incomplete paralysis 1