What is the recommended acute management for Bell's palsy, including corticosteroid dosing, antiviral indications, eye protection, analgesia, facial exercises, follow‑up, and contraindication considerations?

Bell's Palsy Management

Immediate Treatment (Within 72 Hours)

Start oral corticosteroids immediately for all patients ≥16 years old presenting within 72 hours of symptom onset—this is the only proven effective treatment and significantly improves complete recovery rates from 63.6% to 83% at 3 months and from 81.6% to 94.4% at 9 months. 1, 2

Corticosteroid Dosing Regimens

Choose one of these evidence-based regimens:

• Prednisolone 50 mg orally once daily for 10 days (preferred regimen) 1, 3
• Prednisone 60 mg orally once daily for 5 days, then taper by 10 mg daily over next 5 days (alternative regimen) 1, 3

Critical timing: Treatment beyond 72 hours has no proven benefit—do not delay for imaging or laboratory testing in typical presentations. 1, 3

Special Populations Requiring Individualized Assessment

For patients with diabetes mellitus, morbid obesity, previous steroid intolerance, or pregnancy, corticosteroids remain strongly recommended but require specific management:

Diabetes management during steroid therapy:

• Monitor capillary blood glucose every 2-4 hours during first few days 3
• Administer steroids in the morning to align with natural cortisol rhythm 3
• Proactively increase basal insulin and add/increase prandial insulin 3
• For oral hypoglycemic users, add NPH insulin concurrent with morning steroid dose 3
• The therapeutic benefit outweighs temporary hyperglycemia risk 3

Pregnancy: Treat with corticosteroids using careful individualized benefit-risk assessment—the standard regimens apply. 1, 3

Pediatric patients (<16 years): Children have better spontaneous recovery rates (up to 90%), and corticosteroid benefit is less conclusive. Consider treatment on a case-by-case basis with substantial caregiver involvement in shared decision-making, using prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days followed by 5-day taper if treatment is chosen. 1, 3

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Antiviral Therapy

Do NOT prescribe antiviral monotherapy—it is completely ineffective. 1, 3

Optional combination therapy: You may offer valacyclovir 1000 mg three times daily for 7 days PLUS corticosteroids within 72 hours as an option, though the added benefit is minimal (96.5% vs 89.7% complete recovery). 1, 4 Alternative: acyclovir 400 mg five times daily for 10 days. 3

The strongest evidence (2007 NEJM trial with 551 patients) showed no benefit of acyclovir alone or added to prednisolone, while smaller trials suggested modest improvement with combination therapy. 2, 4 Given minimal risks and potential small benefit, combination therapy is reasonable but not essential. 1

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Mandatory Eye Protection Protocol

Implement aggressive eye protection immediately for ALL patients with impaired eye closure—inadequate protection can cause permanent corneal damage. 1, 3

Comprehensive Eye Protection Regimen:

Daytime protection:

• Lubricating ophthalmic drops (e.g., hydroxypropyl methylcellulose) every 1-2 hours while awake 1, 3
• Sunglasses outdoors for wind and particle protection 1, 3

Nighttime protection:

• Ophthalmic ointment at bedtime for sustained moisture 1, 3
• Eye patching or taping (requires careful instruction on proper technique to avoid corneal abrasion) 1, 3
• Moisture chambers using polyethylene covers for severe cases 1, 3

Urgent ophthalmology referral indications:

• Complete inability to close eye 3
• Eye pain, vision changes, redness, discharge, foreign body sensation, or increasing irritation despite protection 1
• Persistent lagophthalmos beyond 3 months (consider tarsorrhaphy, eyelid weight implantation, or botulinum toxin) 1, 3

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Analgesia for Facial Pain

For persistent neuropathic facial pain: Consider gabapentin 1800-3600 mg/day divided three times daily. 5

Do NOT restart or extend corticosteroids beyond the initial 10-day course—evidence supports only the initial treatment window. 5

Most patients begin showing recovery within 2-3 weeks; persistent pain at this stage does not warrant additional corticosteroid therapy. 1, 5

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Facial Exercises and Physical Therapy

Physical therapy and facial exercises are NOT recommended as primary treatment—no proven benefit over spontaneous recovery exists, and evidence consists only of poor-quality trials and case series. 1, 3

Exception: May consider for patients with more severe paralysis developing synkinesis during recovery, though specific protocols lack strong evidence. 5

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Follow-Up Schedule and Reassessment Triggers

Initial Follow-Up Timeline:

• Within 72 hours: Treatment initiation and eye care education 3
• 1-2 weeks: Assess recovery trajectory, reinforce eye protection, identify early complications 3
• 3 months: Mandatory reassessment for all patients with incomplete recovery 1, 3

Urgent Reassessment/Specialist Referral Required For:

At ANY time point:

• New or worsening neurologic findings (suggests alternative diagnosis: stroke, tumor, CNS pathology) 1, 3
• Development of ocular symptoms (urgent ophthalmology referral to prevent corneal damage) 1, 3
• Progressive weakness beyond 3 weeks (red flag for non-Bell's palsy diagnosis) 3

At 3 months:

• Incomplete facial recovery (refer to facial nerve specialist for reconstructive options) 1, 3

Expected Recovery Timeline:

• Most patients begin recovery within 2-3 weeks 1
• Complete recovery typically occurs within 3-4 months 1
• 70% with complete paralysis recover fully within 6 months 1
• 94% with incomplete paralysis recover fully 1, 3
• 30% may experience permanent facial weakness with contractures 1, 3

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Diagnostic Testing Guidance

Do NOT order routine laboratory tests or imaging for typical Bell's palsy presentations—this delays treatment without improving outcomes. 3

Electrodiagnostic testing (ENoG/EMG):

• May offer to patients with complete facial paralysis (NOT for incomplete paralysis) 3
• Perform 3-14 days post-onset for reliable prognostic information 3

• 10% nerve response amplitude indicates excellent prognosis 3

• <10% function carries up to 50% risk of incomplete recovery 3

MRI with and without contrast indicated for:

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

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Contraindicated Therapies

Do NOT use:

• Antiviral monotherapy (completely ineffective) 1, 3
• Surgical decompression (rarely indicated except specific traumatic cases) 1, 3
• Acupuncture (poor-quality trials, indeterminate benefit-harm ratio) 1, 3
• Physical therapy as primary treatment (no proven benefit) 1, 3

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Critical Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces corticosteroid effectiveness 1
• Using standard methylprednisolone dose pack provides only 105 mg prednisone equivalent vs. required 540 mg—significant underdosing 3
• Inadequate eye protection can cause permanent corneal damage 1
• Failing to refer at 3 months for incomplete recovery delays reconstructive options 1, 3
• Missing atypical features (bilateral weakness, isolated branch paralysis, other cranial nerves) requires imaging and specialist evaluation 3
• Improper eye taping technique can cause corneal abrasion—provide careful instruction 1, 3
• Neglecting psychological impact in patients with persistent paralysis can exacerbate depression and social isolation 1, 3