What is the recommended acute management for Bell's palsy?

Acute Management of Bell's Palsy

Start oral corticosteroids immediately 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—combined with aggressive eye protection measures for all patients 16 years and older. 1, 2

Immediate Diagnostic Assessment (Within 72 Hours)

Perform a focused examination to confirm Bell's palsy and exclude alternative diagnoses before initiating treatment 1, 2:

• Verify forehead involvement: Bell's palsy affects the entire ipsilateral face including the forehead, while stroke spares forehead movement 1, 3
• Confirm rapid onset: Symptoms must develop within 72 hours; gradual progression suggests tumor or other pathology 1, 3
• Examine all other cranial nerves: Any involvement of CN V, VI, VIII, IX, X, XI, or XII excludes Bell's palsy and mandates imaging 1, 3
• Rule out bilateral weakness: Bilateral facial palsy suggests Lyme disease, sarcoidosis, or Guillain-Barré syndrome 3
• Check for red flags: Recurrent paralysis on the same side, isolated branch paralysis, or progressive weakness beyond 3 weeks requires MRI 1, 3

Do not order routine laboratory tests or imaging for typical presentations—this delays treatment without improving outcomes 1, 2

First-Line Treatment: Corticosteroids

Initiate corticosteroids within 72 hours—no benefit exists beyond this window 1, 2:

Dosing Regimens (Choose One)

• Prednisolone 50 mg orally once daily for 10 days 1, 2
• Prednisone 60 mg orally once daily for 5 days, then taper over 5 days 1, 2

Evidence Supporting Corticosteroids

Strong 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. Even without treatment, approximately 70% of patients with complete paralysis recover within 6 months, but corticosteroids significantly improve these outcomes 1, 4.

Special Populations

• Diabetes: Corticosteroids are not contraindicated; monitor blood glucose every 2-4 hours during the first few days and adjust diabetes medications proactively 1
• Pregnancy: Treat with oral corticosteroids within 72 hours using the same regimens; the benefit outweighs minimal risks 1, 2
• Children: Consider corticosteroids for severe or complete paralysis after discussing with caregivers, though pediatric evidence is less robust than adult data 1, 2

Antiviral Therapy: Limited Role

Never prescribe antiviral monotherapy—it is completely ineffective and delays appropriate corticosteroid treatment 1, 2, 5.

You may offer combination therapy (corticosteroids plus antivirals) within 72 hours, though the added benefit is minimal 1, 2:

• Valacyclovir 1 g orally three times daily for 7 days, OR 5
• Acyclovir 400 mg orally five times daily for 10 days 1, 5

Some evidence shows 96.5% complete recovery with combination therapy versus 89.7% with steroids alone, but this small benefit must be weighed against minimal additional risk 1.

Mandatory Eye Protection

Implement eye protection immediately for all patients with impaired eye closure to prevent permanent corneal damage 1, 2:

Daytime Protection

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

Nighttime Protection

• 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
• Moisture chambers using polyethylene covers for severe cases 1

Urgent Ophthalmology Referral Triggers

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

Follow-Up Schedule

Early Follow-Up (1-2 Weeks)

Assess recovery trajectory, reinforce eye protection, and identify early complications 1.

Mandatory Reassessment at 3 Months

Refer to a facial nerve specialist if facial recovery is incomplete at 3 months 1, 2. Approximately 30% of patients experience permanent facial weakness requiring reconstructive evaluation 1, 6.

Urgent Reassessment Triggers (At Any Time)

• New or worsening neurologic findings suggesting stroke, tumor, or CNS pathology 1, 2
• Development of ocular symptoms requiring ophthalmology referral 1, 2
• Progressive weakness beyond 3 weeks indicating alternative diagnosis 1

Therapies NOT Recommended

• Physical therapy: No proven benefit over spontaneous recovery 1, 3
• Acupuncture: Poor-quality evidence with indeterminate benefit-harm ratio 1, 3
• Surgical decompression: Rarely indicated except in specialized centers for specific cases 1

Common Pitfalls to Avoid

• Delaying corticosteroids beyond 72 hours eliminates treatment effectiveness 1, 2
• Using antiviral monotherapy is completely ineffective and delays appropriate care 1, 2, 5
• Inadequate eye protection leads to permanent corneal damage, particularly with severe lagophthalmos 1, 2
• Missing atypical features such as bilateral weakness, forehead sparing, or other cranial nerve involvement suggests alternative diagnoses requiring different management 1, 3
• Ordering routine labs or imaging for typical presentations increases costs without benefit and delays treatment 1, 2
• Failing to refer at 3 months delays access to reconstructive options and psychological support for incomplete recovery 1, 6