What is the recommended treatment for Bell palsy?

Treatment of Bell's Palsy

Oral corticosteroids started within 72 hours of symptom onset are the cornerstone of Bell's palsy treatment, combined with aggressive eye protection for all patients with incomplete eyelid closure. 1

Immediate Treatment Algorithm (Within 72 Hours)

Corticosteroid Therapy - First-Line Treatment

• Prescribe prednisolone 50 mg once daily for 10 days (no taper needed) OR prednisone 60 mg once daily for 5 days followed by a 5-day taper for all patients ≥16 years old presenting within 72 hours of symptom onset 1, 2

• Evidence demonstrates 83% complete recovery at 3 months with prednisolone versus 63.6% with placebo (NNT = 6), and 94.4% recovery at 9 months versus 81.6% with placebo (NNT = 8) 1

• Do NOT initiate corticosteroids beyond 72 hours - there is no proven benefit after this critical window 1, 3

• For diabetic patients, corticosteroids remain strongly recommended despite temporary hyperglycemia risk; monitor blood glucose every 2-4 hours and proactively increase insulin doses 1

Antiviral Therapy - Limited Role

• Never prescribe antiviral monotherapy - it is completely ineffective and delays appropriate corticosteroid treatment 1, 2, 4

• May add valacyclovir 1 g three times daily for 7 days OR acyclovir 400 mg five times daily for 10 days to corticosteroids within 72 hours for severe cases, though the added benefit is minimal (96.5% vs 89.7% recovery with steroids alone) 1, 5

• The 2008 Lancet Neurology trial definitively showed valacyclovir alone provided no benefit (hazard ratio 1.01), while prednisolone significantly shortened recovery time (hazard ratio 1.40) 4

Mandatory Eye Protection (All Patients with Impaired Eye Closure)

• Apply lubricating eye drops every 1-2 hours while awake to prevent corneal exposure 1, 2

• Use ophthalmic ointment at bedtime for sustained overnight moisture retention 1, 2

• Tape or patch the eye at night with careful instruction on proper technique to avoid corneal abrasion 1, 2

• Wear sunglasses outdoors to protect against wind and debris 1, 2

• Refer urgently to ophthalmology if complete inability to close the eye, eye pain, vision changes, or signs of corneal damage develop 1

What NOT to Do

• Do NOT order routine laboratory tests or imaging for typical presentations - they delay treatment without improving outcomes 1, 2

• Do NOT perform electrodiagnostic testing in patients with incomplete facial paralysis - it provides no actionable information 1

• Do NOT prescribe physical therapy or acupuncture as primary treatment - they lack proven benefit over spontaneous recovery 1, 6

• Do NOT perform surgical decompression except in rare, highly selected cases at specialized centers 1

Follow-Up and Referral Triggers

• Refer to facial nerve specialist at 3 months if facial recovery remains incomplete 1, 2

• Refer immediately for new or worsening neurologic findings at any point 1, 2

• Refer immediately for development of ocular symptoms at any point 1, 2

• Red flags requiring urgent reassessment: bilateral facial weakness, isolated branch paralysis, other cranial nerve involvement, progressive weakness beyond 3 weeks, or recurrent paralysis on the same side 1, 2

Special Populations

Children

• Have better prognosis with up to 94% spontaneous recovery rates 1, 5
• May consider corticosteroids for severe or complete paralysis after shared decision-making with caregivers, though pediatric evidence is less conclusive than adult data 1, 2

Pregnant Women

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment - the therapeutic benefit outweighs temporary risks 1, 2

Prognosis to Communicate

• Patients with incomplete paralysis: up to 94% complete recovery 1, 2
• Patients with complete paralysis: approximately 70% complete recovery within 6 months 1, 2
• Most patients begin showing recovery within 2-3 weeks 1
• Approximately 30% may experience permanent facial weakness requiring long-term management 1

Management Beyond 72 Hours (Day 5 Presentation)

If a patient presents on day 5 or later, do NOT start corticosteroids as the evidence supporting benefit is specific to the 72-hour window 3, 4. Instead:

• Focus exclusively on aggressive eye protection as outlined above 3
• Educate on natural history - 70-94% will recover spontaneously depending on severity 3
• Monitor for recovery signs within 2-3 weeks 3
• Ensure follow-up at 3 months for specialist referral if incomplete recovery 3

Common Pitfalls

• Starting steroids after 72 hours exposes patients to medication risks without proven benefit 1, 3
• Using antiviral monotherapy is completely ineffective and represents a critical treatment error 1, 2, 4
• Inadequate eye protection leads to preventable permanent corneal damage 1, 2
• Ordering unnecessary imaging for typical presentations delays treatment and increases costs 1, 2
• Missing atypical features (bilateral weakness, forehead sparing, other cranial nerve signs) that suggest stroke, tumor, or Lyme disease rather than Bell's palsy 1, 2