What is the recommended acute management of Bell's palsy, including corticosteroid regimen, antiviral use, eye protection, and follow‑up?

Bell's Palsy Treatment

Start oral corticosteroids immediately if the patient presents within 72 hours of symptom onset—prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper—and implement aggressive eye protection measures for all patients with impaired eye closure. 1, 2

Corticosteroid Therapy (First-Line Treatment)

Corticosteroids are the only proven effective treatment for Bell's palsy and must be initiated within 72 hours of symptom onset. 1, 2

• Recommended regimens: 2

  • Prednisolone 50 mg orally daily for 10 days, OR
  • Prednisone 60 mg orally daily for 5 days, then taper by 10 mg daily over 5 days

• Evidence of benefit: Corticosteroids increase complete recovery rates from 63.6% (placebo) to 83% at 3 months, and from 81.6% to 94.4% at 9 months 2

• Critical timing: Treatment beyond 72 hours provides minimal benefit and exposes patients to medication risks without proven efficacy 1, 2

• For pediatric patients (under 16 years): Consider prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper, though evidence in children is less robust than in adults 2

Antiviral Therapy (Optional Adjunct)

Antiviral monotherapy is ineffective and should never be prescribed alone. 1, 2

• Combination therapy option: May offer valacyclovir 1 g orally three times daily for 7 days OR acyclovir 400 mg orally five times daily for 10 days in addition to corticosteroids within 72 hours 2, 3

• Evidence for combination therapy: Some studies show higher complete recovery rates with combination therapy (96.5%) versus steroids alone (89.7%), though the added benefit is small 2, 4

• Clinical decision: The benefit of adding antivirals is modest but risks are minimal; consider for patients with complete or severe paralysis who present early 5, 4

Eye Protection (Mandatory for All Patients with Lagophthalmos)

Implement comprehensive eye protection immediately to prevent corneal damage—this is non-negotiable regardless of treatment timing. 1, 2

Daytime Protection:

• Lubricating ophthalmic drops (preservative-free artificial tears) every 1-2 hours while awake 2
• Sunglasses outdoors to protect against wind and foreign particles 2

Nighttime Protection:

• Ophthalmic ointment (e.g., erythromycin or lacri-lube) applied at bedtime for sustained moisture 2
• Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 2
• Consider moisture chambers using polyethylene covers for severe cases 2

Urgent Ophthalmology Referral Indications:

• Complete inability to close the eye 2
• Eye pain, vision changes, redness, or discharge 1
• Signs of corneal exposure or damage 2

Follow-Up and Reassessment

Establish clear follow-up intervals with specific triggers for specialist referral. 2

Initial Follow-Up:

• Reassess within 1-2 weeks to monitor recovery trajectory, reinforce eye protection, and identify early complications 2

Mandatory Specialist Referral Triggers:

• Incomplete facial recovery at 3 months after symptom onset 1, 2
• New or worsening neurologic findings at any point (suggests alternative diagnosis) 1, 2
• Development of ocular symptoms at any point (requires ophthalmology evaluation) 1, 2
• Progressive weakness beyond 3 weeks (red flag for non-Bell's palsy etiology) 2

Atypical Features Requiring Imaging (MRI with and without contrast):

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

Natural History and Prognosis

Most patients recover spontaneously, but corticosteroids significantly improve outcomes. 1, 2

• Incomplete paralysis: Up to 94% complete recovery rate 1, 2
• Complete paralysis: Approximately 70% complete recovery within 6 months without treatment 1, 2
• Typical recovery timeline: Most patients show signs of improvement within 2-3 weeks, with complete recovery by 3-4 months 1, 2
• Permanent sequelae: Approximately 30% may experience some degree of permanent facial weakness with muscle contractures 2

Special Populations

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using standard dosing 2
• Eye protection measures are essential and safe in pregnancy 2
• Consider combination therapy with antivirals on individualized basis 2

Children:

• Better prognosis with higher spontaneous recovery rates (up to 90%) than adults 2, 3
• Evidence for corticosteroid benefit is less conclusive in pediatrics 2
• Involve caregivers in shared decision-making regarding treatment 2

Therapies NOT Recommended

Avoid these interventions as they lack proven benefit or may cause harm: 2

• Antiviral monotherapy (ineffective) 1, 2
• Physical therapy (no proven benefit over spontaneous recovery, though may help with synkinesis in severe cases) 2, 3
• Acupuncture (poor-quality evidence, indeterminate benefit-harm ratio) 2
• Surgical decompression (rarely indicated except in specialized circumstances) 2
• Corticosteroids initiated beyond 72 hours (no evidence of benefit) 1, 2

Common Pitfalls to Avoid

• Starting steroids after 72 hours: Provides minimal benefit and exposes patients to medication risks 1, 2
• Prescribing antivirals alone: Completely ineffective as monotherapy 1, 2
• Inadequate eye protection: Can lead to permanent corneal damage in patients with lagophthalmos 1, 2
• Failing to refer at 3 months: Delays access to reconstructive options and specialist evaluation 1, 2
• Missing atypical features: Bilateral weakness, isolated branch paralysis, or other cranial nerve involvement suggest alternative diagnoses requiring imaging 2
• Using standard methylprednisolone dose packs: These provide only 105 mg prednisone equivalent versus the required 540 mg over 14 days, representing significant underdosing 2