Treatment for Bell's Palsy
Immediate First-Line Treatment
Start oral corticosteroids within 72 hours of symptom onset—this is the only proven treatment that significantly improves facial nerve recovery, with 83% complete recovery at 3 months versus 63.6% with placebo. 1
Corticosteroid Regimen (Choose One)
- Prednisolone 50 mg once daily for 10 days (preferred regimen) 1
- Prednisone 60 mg daily for 5 days, then taper by 10 mg daily over next 5 days (alternative) 1
Critical timing: Treatment initiated beyond 72 hours provides minimal to no benefit and should generally not be started. 1, 2 The therapeutic window exists because early corticosteroids reduce facial nerve inflammation before permanent damage occurs. 2
Evidence Strength
The benefit is substantial and well-established: at 9 months, 94.4% of prednisolone-treated patients achieve complete recovery versus 81.6% with placebo. 1, 3 This represents a number needed to treat of 11 to prevent one unsatisfactory outcome. 4
Antiviral Therapy Decision
Never prescribe antiviral agents as monotherapy—they are completely ineffective when used alone. 1, 2
Optional Combination Therapy
You may offer (not mandate) the addition of antiviral therapy to corticosteroids within 72 hours, though the added benefit is minimal: 1
- Valacyclovir 1000 mg three times daily for 7 days 5, 6
- Acyclovir 400 mg five times daily for 10 days (alternative with lower bioavailability) 1
Rationale for optional use: Some studies show combination therapy achieves 96.5% complete recovery versus 89.7% with steroids alone 6, while the largest trials show no additional benefit 3, 5. The AAO-HNS classifies this as an "option" rather than a recommendation because the benefit is small but risks are minimal. 1
Eye Protection Protocol (Mandatory)
Implement aggressive eye protection immediately for any patient with impaired eye closure—failure to do so can result in permanent corneal damage. 1
Daytime Protection
- Lubricating drops (e.g., hydroxypropyl methylcellulose) every 1-2 hours while awake 1
- Sunglasses outdoors to protect against wind and particles 1
Nighttime Protection
- Ophthalmic ointment at bedtime for sustained moisture retention 1
- Eye taping or patching with careful instruction on proper technique to avoid corneal abrasion 1
- Moisture chambers (polyethylene covers) for severe cases 1
Urgent Ophthalmology Referral Indications
- Complete inability to close the eye 1
- Eye pain, vision changes, redness, or discharge 1
- Signs of corneal exposure or damage 1
Diagnostic Testing Approach
Do NOT order routine laboratory tests or imaging for typical Bell's palsy presentations—this only delays treatment without improving outcomes. 1
When to Order Tests
Electrodiagnostic testing (ENoG/EMG): Offer only to patients with complete facial paralysis, performed 3-14 days post-onset. 1 Testing before 7 days or after 14-21 days is unreliable. 1
MRI with and without contrast: Order only for atypical features: 1
- Recurrent paralysis on same side
- Isolated branch paralysis (not affecting forehead)
- Other cranial nerve involvement
- Progressive weakness beyond 3 weeks
- No recovery after 3 months
- Bilateral facial weakness
Follow-Up Schedule
Early Follow-Up (1-2 Weeks)
Mandatory 3-Month Reassessment
Refer to facial nerve specialist if facial recovery is incomplete at 3 months. 1 Approximately 30% of patients may experience permanent facial weakness requiring reconstructive options. 1
Urgent Reassessment Triggers (Any Time)
- New or worsening neurologic findings 1
- Development of ocular symptoms 1
- Progressive weakness beyond expected timeline 1
Special Populations
Diabetes
Diabetes is NOT a contraindication to corticosteroids—the therapeutic benefit outweighs temporary hyperglycemia risk. 1
- Monitor capillary glucose every 2-4 hours during first few days 1
- Dose steroids in the morning to align with cortisol rhythm 1
- Increase basal insulin and add/increase prandial insulin proactively 1
- Consider adding NPH insulin concurrent with morning steroid dose 1
Pregnancy
Treat pregnant women with oral corticosteroids within 72 hours using individualized risk-benefit assessment. 1 Eye protection measures are essential and safe in pregnancy. 1
Children
Children have better prognosis with higher spontaneous recovery rates than adults. 1, 2 Evidence for corticosteroid benefit in children is less conclusive, so involve caregivers in shared decision-making. 1 Use weight-based dosing: prednisolone 1 mg/kg/day (maximum 50-60 mg) for 5 days, then 5-day taper. 1
Therapies NOT Recommended
Do not use: 1
- Physical therapy (no proven benefit over spontaneous recovery)
- Acupuncture (poor-quality trials, indeterminate benefit-harm ratio)
- Surgical decompression (rarely indicated except in specialized trauma cases)
Expected Recovery Timeline
- Most patients begin recovery within 2-3 weeks 1, 2
- Complete recovery typically occurs within 3-4 months 1
- Incomplete paralysis: up to 94% complete recovery 1, 2
- Complete paralysis: approximately 70% complete recovery within 6 months 1, 2
Common Pitfalls to Avoid
- Starting steroids after 72 hours: No proven benefit and exposes patients to medication risks unnecessarily 1, 2
- Using antivirals alone: Completely ineffective as monotherapy 1, 2
- Inadequate eye protection: Can lead to permanent corneal damage, especially with severe lagophthalmos 1
- Failing to refer at 3 months: Delays access to reconstructive options and psychological support 1
- Ordering unnecessary imaging: Delays treatment in typical presentations 1
- Using standard methylprednisolone dose packs: These provide only 105 mg prednisone equivalent versus the required 540 mg over 14 days, representing significant underdosing 1